mastitis lisa rahangdale, md rid seminar october 26, 2004
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MastitisMastitis
Lisa Rahangdale, MDLisa Rahangdale, MD
RID SeminarRID Seminar
October 26, 2004October 26, 2004
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MastitisMastitis An acute inflammation of the An acute inflammation of the interlobular connective tissue interlobular connective tissue
within the mammary glandwithin the mammary gland
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OutlineOutline
• Epidemiology
• Presentation
• Predisposing factors
• Microbiology
• Treatment
• Complications
• Effect on breast milk
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EpidemiologyEpidemiology
• Incidence 2-33%– ACOG reports 1-2% in U.S.– Most common worldwide <10%
• Most common 2nd-3rd week postpartum– 74-95% in first 12 weeks– Can occur anytime in lactation
WHO 2000
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PresentationPresentation
• Systemic illness: Chills, myalgias
• Fever of ≥ 38.5
• Tender, hot, swollen wedge-shaped erythematous area of breast
• Usually one breast
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Differential DiagnosisDifferential Diagnosis
• Fullness: bilateral, hot, heavy, hard, no redness
• Engorgement: bilateral, tender, +/- fever, minimal diffuse erythema
• Blocked Duct: painful lump with overlying erythema, no fever, feel well, particulate matter in milk
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Differential DiagnosisDifferential Diagnosis
• Galactocele: smooth rounded swelling (cyst)
• Abscess: tender hard breast mass, +/- fluctuance, skin erythema, induration, +/- fever
• Inflammatory Breast Carcinoma: unilateral, diffuse and recurrent, erythema, induration
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Causes and Causes and Predispsing factorsPredispsing factors
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CausesCauses
• Milk Stasis– Stagnant milk increases pressure in breast
leading to leakage in surrounding breast tissue
– Milk, itself, causes an inflammatory response
• +/- Infection– Milk provides medium for bacterial growth
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CausesCauses
• Study of 213 ♀, 339 breasts• 3 groups
– Milk stasis (bacteria<10^3, leuk<10^6)– Noninfectious inflammation (bacteria <10^3, leuk
>10^6)– Infectious (bacteria >10^3, leuk>10^6)
• Randomized treatment – No intervention– Systematic emptying of breast– Infectious group with 3rd intervention: antibiotics (PCN,
Amp, Erythro) and systematic emptying
Thomsen 1984
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Treatment N Sx duration (mean) p value
Milk Stasis No treatment 63 2.3 d Emptying 63 2.1 d
Noninfectious No treatment 24 7.9 d Emptying 24 3.2 d p<.001
Infectious No treatment 55 6.7 d Emptying 55 4.2 d p<.001 Abx +Emptying
55 2.1 d p<.001
Thomsen 1984
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CausesCauses
• “Poor results”– Milk stasis (10) – 3 recurrences, 7 impaired
lactation– Noninfectious (20) – 13 recurrences– Infectious (76 – only 2 in Abx group) – 6
abscesses, 21 recurrences
• Could not clinically tell difference between the groups without lab data.
• Conclusion: Treat with antibiotics
Thomsen 1984
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Predisposing factorsPredisposing factors• Improper nursing technique
– Timing of feeds– Poor attachment
• Oversupply of milk– Overabundant milk supply– Lactating for multiples– Rapid weaning– Blocked nipple pore or duct
• Pressure on Breast– Tight Bra– Car seatbelt (yes, this is actually listed)– Prone sleeping position
WHO 2000, Academy of Breastfeeding Medicine 2004
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Predisposing factorsPredisposing factors
• Damaged nipple (nipple fissure)• Primiparity• Previous history of mastitis• Maternal or neonatal illness• Maternal stress• Work outside the home• Trauma• Genetic
WHO 2000, Michie 2003, Barbosa-Cesnik 2003, Academy of Breastfeeding Medicine, 2004
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Predisposing factorsPredisposing factors
• U.S. cohort of 946 Breastfeeding ♀• Telephone interviews• 9.5% mastitis (64% diagnosed via telephone)• Average symptoms for 4.9 days• 88% prescribed medications
– 86% antibiotics (46% cephelexin)– 17% analgesics
• No cultures performed
Foxman 2002Foxman 2002
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Predisposing factorsPredisposing factors
• H/O mastitis with previous child (OR 4.0, 95% CI 2.94, 6.11)
• Cracks and nipple sores in same week as mastitis (OR 3.4, 95% CI 2.04, 5.51)
• Antifungal nipple cream in 3 wk interval of mastitis (OR 3.3, 95% CI 1.92, 5.62)
• Manual breast pump (for ♀ with no prior history) (OR 3.3, 95% CI 1.92, 5.62)
• Feeding <10 times per day in same week– (for 7-9 times OR 0.6, 95% CI 0.41, 1.01)– For ≤ 6 tmes, OR 0.4, 95% CI 0.19, 0.82)
Foxman 2002Foxman 2002
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Foxman 2002Foxman 2002
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Foxman 2002Foxman 2002
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MicrobiologyMicrobiology
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MicrobiologyMicrobiology
• Detection of pathogens difficult– Usually nasal/skin flora– Difficult to avoid contamination
• Milk culture– Encouraged in hospital acquired, recurrent
mastitis, or no response in 2 days
WHO 2000
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MicrobiologyMicrobiology
• Staph Aureus
• Coag neg staph
• Also, Group A and B βhemolytic Strep, E Coli, H. flu
• MRSA
• Fungal infections
• TB where endemic – 1% of cases
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MRSA in SFMRSA in SF
Charlebois 2004
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MRSA in SFMRSA in SF
• SFGH– Community Acquired: 70%– Hospital Acquired: 50%
• Moffitt– Community Acquired: 49%– Hospital Acquired: 37%
• VA 45%
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MRSAMRSA
• Risk factors for Community Acquired in SF– Homelessness (p=.015)– Injection drugs (p=.02)
• Difference in Strains– Hospital: SCCmec Type 2
• More resistant• May include Gent, Eryth, Quinolones, TMP/SMX, Clinda
– Community: SCCmec Type 4• Susceptible to most ABX other than β lactams
• Carriage can be months to years
Charlebois 2004
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Postpartum MRSA Postpartum MRSA
• Case reports – Initially reported in Midwest
• NYC case-control study– 8 cases (4 mastitis 3 breast abscesses)– All CA-MRSA
• Resistant to β lactams• Susceptible to Clinda, Flouroquinolones, TMP-
SMX, Gent, Rifampin, Tetracycline
– No transmission route identified– Associated with GBBS (p=.03)
Saiman 2003
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Fungal infectionsFungal infections
• Based on case reports that anti-fungal cream improves sx
• Case reports of cyptococcal infection• Most common: Candida Albicans
– Genital tract Newborn oral colonization
• May lead to nipple fissure• Thought to be associated with deep, shooting
pains and nipple discomfort• Most commonly treated with fluconozole to ♀,
oral nystatin to infant
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Fungal infections:Fungal infections:Is Candida associated with shooting breast pain?Is Candida associated with shooting breast pain?
Case series on deep breast pain– Isolated Candida in 5/20 (20%) patients– Candida twice as often in superficial pain than bacteria– Bacteria more often found in deep pain
• Case-control study, Australia– 61 nipple pain, 64 w/out nipple pain, 31 non-lactating– More Candida in pain(19%) than control (3%), p<.01– Also, S. Aureus assoc w/ pain (p<.001) and fissures (p<.001)– No Candida/S Aureus in non-lactating group
• Brazilian study showed 32% colonization in milk of Asx ♀
Amir 1996, Thomassen 1998, Carmichael 2001
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TreatmentTreatment
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TreatmentTreatment
• Supportive Therapy– Rest, fluids, pain medication, anti-inflammatory
agents, encouragement
• Continue breast feeding• Antibiotics that cover Staph and Strep
– Culture results– Severe symptoms– Nipple fissure– No improved sx after 12-24 hours of milk removal
• 86% of women in the U.S. get treated with Abx
WHO 2000, Foxman 2002
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TreatmentTreatment(ACOG)(ACOG)
• Dicloxicillin 500 mg qid
• Erythromycin if PCN allergic
• If resistant to treatment penicillinase-producing staph, then vancomycin or cefotetan until 2 days after infection subsides
• Minimum treatment 10-14 days
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TreatmentTreatment(Alternative)(Alternative)
• Therapeutic U/S
• Accupunture
• Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis
• Cabbage leaves
• Avoid drinks like coffee with methylxanthines, decreasing fat intake
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ComplicationsComplications
(Other bad things related to (Other bad things related to mastitis)mastitis)
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AbscessAbscess
• Most common in first 6 weeks • 5-11% of mastitis cases• Affect future lactation in 10% of affected ♀• Treatment: I & D, U/S guided needle drainage
– Cohort of 19 ♀ with abscess: 18/19 successfully tx with U/S-guided needle drainage
– Cohort of 30 ♀ (33 abscesses): Tx with needle drg (no U/S), cure rate 82%, success assoc with smaller volume of pus (4 ml vs 21.5 ml, p=.002) and presented earlier (5 vs 8.5 days, p=/006)
Karstrup 1993, WHO 2000, Schwartz 2001
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AbscessAbscess
• Prospective cohort128 BF ♀ with infection– 102 mastitis (80%)– 26 abscess (20%)
• No differences b/t groups by age, parity, localization of infection, cracked nipples, + milk cultures, mean lactation time
• Duration of symptoms: only independent variable favoring abscess development
Dener 2003
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Other ComplicationsOther Complications
• Distortion of breast • Chronic inflammation
Michie 2003, WHO 2000
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Granulomatous MastitisGranulomatous Mastitis
• Noncaseating granulomas in a lobular distribution
• Differential Diagnosis– TB mastitis – Foreign body– Fat necrosis– Autoimmune: sarcoid, erythema nodusum,
polyarthritis• Presentation
– Unilateral Breast lump– No infection identified at presentation
Heer 2003, Goldberg 2000
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Granulomatous MastitisGranulomatous Mastitis
• Can mimic Breast Ca on clinical, radiological, and cytological exams
• Diagnosis: Histology• Treatment:
– Antibiotics not helpful– Corticosteroids– Excision biopsy
• Limited literature, but no clear association with breast feeding, OCPs
Heer 2003, Goldberg 2000
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Subclinical MastitisSubclinical Mastitis
• No symptoms, usually unilateral• Reduction in milk output• Diagnosis: Increased milk sodium• Causes
– Milk stasis, poor nutrition, +/- bacteria
• Public Health implication– Poor infant growth– Increased risk of HIV transmission
• Natural Hx and clinical implication unclear
Michie 2003, Filteau 2003
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Effect on MilkEffect on Milk
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Immune FactorsImmune Factors
• IgA is predominant in milk
• Increased immune factors from both plasma and local epithelial cells
• No adverse events documented in peds– Poor growth documented likely related to poor
milk production– Contradictory studies showing benefit or harm
• Interest in pediatric vaccine development
Michie 2003, Filteau 2003
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Increased HIV transmission riskIncreased HIV transmission risk
• Milk VL increases 10-20 fold
• Alternating breast/bottle increased risk
• Role of free virus vs cell bound virus unclear
• If ♀ must breast feed, then pump on affected breast (pasteurize) and feed on unaffected
• Subclinical mastitis: Problem -Lab dxs only
Michie 2003, Filteau 2003
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Is there anything else?Is there anything else?
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Nipple piercing and mastitisNipple piercing and mastitis
• Review of 10 case reports on Med-line• 7 female, 3 male• 5 right breast, 4 left, 1 both• Interval from piercing to treatment: 20.8 wks (2-52)• Symptoms: 1 week to several months• Complications: endocarditis, heart valve operation,
prosthesis infection, metal foreign body in breast tissue, reoperation for recurrent infection, psychologic stress secondary to Breast CA dxs
• Conclusion: – Risk of nipple piercing under-documented and may be 10-20%– Healing can take 6-12 months
Jacobs 2003
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Take HomeTake Home
• Mastitis can decrease motivation to breast feed
• Remember Milk cultures if not getting better
• OK to Breastfeed (except HIV+)
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