Rosen & Barkin's 5-Minute Emergency Medicine Consult (438 page)

DIAGNOSIS

• Fever and chills
  
  • Temperature usually >38.3°C (101°F)
    
• General malaise
  
• Tachycardia
  
• Breast pain, induration, erythema, warmth; usually unilateral
  
• Onset typically 2–3 wk to months postpartum while breast-feeding
  
• Rare during 1st postpartum week
  

• Flu-like symptoms
  
• Fever, malaise, and myalgia
  
• Breast redness, swelling
  
• Breast pain
  
• Decreased milk outflow
  

• Breast is:
  
  • Warm
    
  • Tender
    
  • Indurated
    
  • Erythematous – often in a wedge-shaped pattern
    
• Usually unilateral breast involvement
  
• Purulent nipple discharge can occur
  
• Axillary lymph nodes may be enlarged
  

Physical exam with special attention to detecting abscess:

• Abscess is frequently difficult to detect, but is more common in periareolar area
  
• Purulent nipple discharge with palpation
  

• In neonates:
  
  • Consider the presence of abscess formation and systemic symptoms of infection (e.g., lethargy, poor feeding, fever)
    
  • Sepsis workup may be needed if neonates are febrile and ill appearing
    
  • A complete blood count (CBC) with differential and blood culture need to be considered before the initiation of antibiotics
    

Breast milk culture is usually not required

• Consider breast US if abscess is suspected
  
• Mammography is not indicated acutely
  

• Breast engorgement:
  
  • Transient fever <39°C of 4–16 hr duration
    
  • Appearing 48–72 hr postpartum
    
  • Bilateral nonerythematous engorgement
    
• Carcinoma (inflammatory)
  
• Cyst, tumor
  
• Abscess formation
  

TREATMENT

Generally no pre-hospital treatment needed

No specific stabilization

• Continue breast-feeding:
  
  • Child and mother are colonized with the same organisms
    
  • Milk from a breast with mastitis may be protective
    
  • If an infant does not like the taste of milk from a breast with mastitis, then encourage the mother to pump and discard
    
• Massage
  
• Hot/cold therapy
  
• Improve breast-feeding technique:
  
  • May need a lactation consultant
    
• Maintain good maternal hydration.
  
• If mild symptoms and early in disease, antibiotics may not be necessary.
  
• Oral antibiotics for 7–14 days:
  
  • β-Lactamase–resistant penicillin (e.g., dicloxacillin)
    
  • 1st-generation cephalosporin (e.g., cefalexin)
    
  • Clindamycin or trimethoprim/sulfamethoxazole (TMP/SMX) or erythromycin if penicillin allergic
    
• Surgical consultation if evidence of abscess
  
• If considering methicillin-resistant
  S. aureus
  (MRSA), treat according to local susceptibility patterns:
  
  • Clindamycin
    
  • TMP/SMX
    
  • Vancomycin
    

• Amoxicillin/clavulanate: 875 mg PO q12h
  
• Cephalexin: 500 mg PO q6h for 10 days
  
• Clindamycin: 300 mg PO q6h for 10 days
  
• Dicloxacillin: 500 mg PO q6h for 10 days (1st-line treatment)
  
• Erythromycin: 500 mg PO q6h for 10 days
  
• Mupirocin 2% ointment TID
  
• TMP/SMX: 160/800 mg PO q12h:
  
  • Avoid in compromised infants and healthy infants <2 mo old
    
• If MRSA positive: Vancomycin 1 g IV q12h
  

Dicloxacillin

• Amoxicillin/clavulanate
  
• Cephalexin
  
• Erythromycin
  
• TMP/SMX
  

FOLLOW-UP

• Incision and drainage under general anesthesia may be necessary and require admission
  
• Immunocompromised or evidence of septicemia
  
• Patients with diabetes may account for 1/3 of mastitis cases
  
• Neonatal mastitis generally requires admission
  

• Most patients may be managed in outpatient setting
  
• Most symptoms resolve within 48 hr of therapy
  
• In simple mastitis, breast-feeding may be continued, including using affected breast:
  
  • Gently massage to enhance drainage
    
  • Counsel that this will not harm baby
    
• Breast support, warm compresses, and analgesia for comfort
  
• In frank abscess, discontinue breast-feeding until purulent discharge resolves
  
• Follow-up should be arranged to exclude diagnosis of inflammatory carcinoma
  

• Patients should follow up with primary care physician
  
• Lactation consultant may be helpful
  

• Most cases respond to lactation and warm compresses without antibiotics
  
• Cessation of breast-feeding will lead to increased milk stasis and increased risk for abscess formation
  
• One of the most common complications of mastitis is cessation of breast-feeding
  

• Dixon JM, Khan LR. Treatment of breast infection.
  BMJ.
  2011;342:d396.
  
• Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women.
  Cochrane Database Syst Rev
  . 2009;(1):CD005458.
  
• Schoenfeld EM, McKay MP. Mastitis and methicillin-resistant Staphylococcus aureus (MRSA): The calm before the storm?
  J Emerg Med
  . 2010;(38):e31–e34.
  
• Spencer JP. Management of mastitis in breastfeeding women.
  Am Fam Physician
  . 2008;78:727–731.
  
• Stafford I, Hernandez J, Laibl V, et al. Community acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization.
  Obstet Gynecol.
  2008;112:533–537.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abscess
  
• Cellulitis
  
• Community-acquired MRSA
  

CODES

• 611.0 Inflammatory disease of breast
  
• 675.24 Nonpurulent mastitis associated with childbirth, postpartum condition or complication
  
• 778.7 Breast engorgement in newborn
  

BASICS

• Inflammation of the mastoid air cells of the temporal bone, generally caused by direct extension of acute purulent otitis media
  
• Middle ear and mastoid air cells are contiguous via the aditus to mastoid antrum
  
• Fluid accumulation from closure of channel due to otitis media creates opportunity for infection
  
• Manifestation ranges from clinically insignificant inflammation of mastoid air cells to infection and destruction of the bone
  
• Acute mastoiditis:
  
  • Occurs to some degree in all cases of otitis media
    
  • Early signs and symptoms are those of acute otitis media
    
  • Usually secondary to contamination with infectious material trapped in the mastoid by inflammatory obstruction of the channel between middle ear and mastoid air cells
    
• Acute mastoiditis with periostitis:
  
  • As infection progresses, periosteum of the mastoid bone is involved, causing periostitis
    
  • Subperiosteal abscess may be present
    
• Acute mastoid ostitis (also called coalescent mastoiditis):
  
  • Progression of the infection within the mastoid air cells leads to destruction of the mastoid trabeculae, causing coalescence of bony trabeculae
    
  • Mastoid empyema or a draining fistula may be present
    
  • May progress to severe head and neck complications if untreated
    
• Masked mastoiditis:
  
  • Mastoid infection, which lingers after an acute otitis media has been treated
    
  • May progress to acute or coalescent mastoiditis
    
• Chronic mastoiditis:
  
  • Infection lasting >3 mo
    
• Mastoiditis can be a complication of a primary disorder:
  
  • Leukemia
    
  • Mononucleosis
    
  • Sarcoma of the temporal bone
    
  • HIV
    
  • Kawasaki disease
    
• Mastoiditis used to be more common prior to the use of antibiotics for acute otitis media
  
• More common in young children and infants