Breast Infection / Inflammation

 

Puerperal mastitis (or inflammation of the breast tissue) may or may not be associated with infection.  Non-infectious mastitis can be due to an accumulation of milk causing an inflammatory response in the breast.  Infectious mastitis can occur when accumulated milk allows bacteria to grow.  Infectious mastitis may lead to a breast abscess, which occurs when a localised collection of pus develops

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Definition

Infection, usually bacterial, of the breast tissue, either cellulitis or abscess formation

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Exclude Red Flag Symptoms

Exclude the following red flag symptoms:

  1. Systemically unwell, clear abscess or necrotic compromised skin requires urgent referral: contact the breast unit secretary to speak to the duty breast surgeon; if they are unavailable consider contacting the acute surgical team
  2. If any doubt that the infection/inflammation may not be settling, seek advice from a breast surgeon sooner rather than later (especially if the weekend is approaching)
  3. Patient over 50 years (higher risk of underlying malignancy)
  4. Inflammatory cancer and its clinical presentations:  peau d’orange, indrawing of skin or nipple-areola complex (NAC)

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Management

To relieve pain and discomfort:

  • Prescribe a simple analgesic, such as paracetamol or ibuprofen

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For lactating women:

  • Prescribe an oral antibiotic if the woman has a nipple fissure that is infected, symptoms have not improved (or are worsening) after 12–24 hours despite effective milk removal, and/or breast milk culture is positive
    • If breast milk culture results are available, treat with an antibiotic that the organism is sensitive to
    • If breast milk culture results are not available:
      • Treat empirically with flucloxacillin 500 mg four times a day for 10–14 days
      • If the woman is allergic to penicillin, prescribe either erythromycin 250–500 mg four
  • Prescribe an oral antibiotic for all women with non-lactational mastitis:
    • Prescribe co-amoxiclav 500/125 mg three times a day for 10–14 days
    • If the woman is allergic to penicillin, prescribe a combination of erythromycin (250–500 mg four times a day) or clarithromycin (500 mg twice a day) plus metronidazole (500 mg three times a day) for 10–14 days

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Review at 48 hours:

  • If symptoms improve complete the antibiotic course; if symptoms deteriorate refer
  • If symptoms are slow to resolve or are recurring, refer via the KMCC NG12 breast rapid referral proforma

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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