1. Mastitis Lisa Rahangdale, MD RID Seminar October 26, 2004

2. Mastitis An acute inflammation of the interlobular connective tissue within the mammary gland An acute inflammation of the interlobular connective tissue within the mammary gland

3. Outline Epidemiology Presentation Predisposing factors Microbiology Treatment Complications Effect on breast milk

4. Epidemiology Incidence 2-33% –ACOG reports 1-2% in U.S. –Most common worldwide <10% Most common 2 nd -3 rd week postpartum –74-95% in first 12 weeks –Can occur anytime in lactation WHO 2000

5. Presentation Systemic illness: Chills, myalgias Fever of ≥ 38.5 Tender, hot, swollen wedge-shaped erythematous area of breast Usually one breast

6. Differential 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

7. Differential 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

8. Causes and Predispsing factors

9. Causes 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

10. Causes Study of 213 ♀, 339 breasts 3 groups –Milk stasis (bacteria<10^3, leuk<10^6) –Noninfectious inflammation (bacteria 10^6) –Infectious (bacteria >10^3, leuk>10^6) Randomized treatment –No intervention –Systematic emptying of breast –Infectious group with 3 rd intervention: antibiotics (PCN, Amp, Erythro) and systematic emptying Thomsen 1984

11. TreatmentNSx duration (mean) p value Milk Stasis No treatment 632.3 d Emptying 632.1 d Noninfectious No treatment 247.9 d Emptying 243.2 dp<.001 Infectious No treatment 556.7 d Emptying 554.2 dp<.001 Abx +Emptying 552.1 dp<.001 Thomsen 1984

12. Causes “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

13. Predisposing 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

14. Predisposing 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

15. Predisposing 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 2002

16. Predisposing 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 2002

19. Microbiology

20. Microbiology 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

21. Microbiology 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

22. MRSA in SF Charlebois 2004

23. MRSA in SF SFGH –Community Acquired: 70% –Hospital Acquired: 50% Moffitt –Community Acquired: 49% –Hospital Acquired: 37% VA 45%

24. MRSA 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

25. 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

26. Fungal 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

27. Fungal infections: 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

28. Treatment

29. Treatment 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

30. Treatment (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

31. Treatment (Alternative) Therapeutic U/S Accupunture Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis Cabbage leaves Avoid drinks like coffee with methylxanthines, decreasing fat intake

32. Complications (Other bad things related to mastitis)

33. Abscess 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

34. Abscess 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

35. Other Complications Distortion of breast Chronic inflammation Michie 2003, WHO 2000

37. Granulomatous 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

38. Granulomatous 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

39. Subclinical 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

40. Effect on Milk

41. Immune 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

42. Increased 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

43. Is there anything else?

44. Nipple 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

45. Take Home Mastitis can decrease motivation to breast feed Remember Milk cultures if not getting better OK to Breastfeed (except HIV+)