​Kembara Xtra - Medicine - Mastitis

​Kembara Xtra - Medicine - Mastitis 
Aareola, nipple, and subcutaneous fat may also be affected by mastitis, which is an inflammation of the breast parenchyma.
 Typically linked to bacterial infection (and postpartum mothers' milk stasis)
 May or may not be lactational.
Usually an acute illness, cystic mastitis can develop into a chronic one.

In the period of shorter hospital stays for mothers and babies, pandemic forms are infrequent and primarily afflict females during the puerperium.
Neonatal form - Posttraumatic: decorative nipple piercing raises the risk of bacterial transmission to deeper breast structures; Staphylococcus aureus is the main pathogen.
Neonatal form occurs at 1 to 5 weeks of age, with equal gender risk and unilateral presentation. Pediatric form occurs at or around or after puberty, with 82% of cases in girls. Incidence 3-20% of breastfeeding mothers develop nonepidemic mastitis, with greatest incidence among breastfeeding mothers 2 to 6 weeks postpartum.

Pathophysiology and Etiology 

Inflammatory cell infiltration of breast parenchyma and surrounding tissues; microabscesses along milk ducts and surrounding tissues; nonpuerperal (infectious) S. aureus, including methicillin-resistant S. aureus (MRSA); Bacteroides species; Peptostreptococcus; Staphylococcus (coagulase negative); Enterococcus faecalis; Histoplasma capsulatum; Salmonella
 Rare secondary site for tuberculosis in endemic areas (1% of mastitis cases in these areas): single breast nodule with mastalgia. Puerperal (infectious) S. aureus (including MRSA), Streptococcus pyogenes (group A or B), Enterobacteriaceae, Corynebacterium spp., Bacteroides spp., Staphyloc
There have also been cases of tuberculosis mastitis in individuals exposed to TNF-inhibitors and other immunomodulating drugs in nonendemic locations.
Idiopathic granulomatous mastitis is related with a higher risk of developing chronic cystic mastitis and Corynebacterium spp.
 Favoritism for Hispanic and Asian women
 Corynebacterium spp. infection, oral contraceptive use, hypoprolactinemia with galactorrhea, 1-antitrypsin deficiency, and breast trauma
The majority of women have breastfed in the five years prior.
In the context of exogenous progesterone and estrogen therapy, new examples of male to female transgender individuals have been documented.
autoimmune; lupus
Puerperal - Retrograde migration of surface bacteria up milk ducts - Bacterial trapping behind plugged milk in the ductal outflow tracts - Bacterial migration from nipple fissures to breast lymphatics - Secondary monilial infection in the face of recurrent mastitis or diabetes - Seeding from mother to neonate in a cyclical fashion - Nonpuerperal - a number of causes including:  An uncommon cause is lupus.

Breastfeeding Milk stasis: insufficient breast emptying (scarring from prior breast surgery [breast reduction, biopsy, or partial mastectomy], scarring from prior mastitis), breast engorgement: cessation of breastfeeding, milk surplus, blocked ducts
The S. aureus dominant organism increases the probability of bacterial transfer to deeper breast structures following nipple damage.
 Maternal diabetes Maternal HIV Smoking Neonatal colonization with epidemic Staphylococcus Neonatal—occurs more frequently in bottle-fed babies; may be associated to manual expression of "witch's milk" and can cause fatal necrotizing fasciitis 


Prevention 

Breastfeeding mothers should regularly empty both breasts and take care of their nipples to prevent fissures. They should also practice good cleanliness, washing their hands and breast pumps after each use.


Accompanying Conditions 

breast infection

Fever >38.5°C, malaise, and myalgia are the diagnoses.
Vomiting and nausea as well as possible breast mass as well as localized breast discomfort, stiffness, heat, swelling, and redness.
HISTORY
Breast ache and "burning hot cords in chest wall"

Clinical examination findings include: breast sensitivity; localized induration, redness, and warmth; and a peau d'orange appearance to the skin above the breast.

Differential diagnosis: Tumor, including inflammatory breast cancer; Abscess (bacterial, fungal, idiopathic granulomatous mastitis, tuberculosis); Idiopathic granulomatous mastitis; Wegener granulomatosis; Sarcoidosis; Foreign-body granuloma.
Vasospasm (which could be a symptom of Raynaud): If your child has thrush or you notice burning and pain in your nipples, you may have a yeast infection.
Consider monilial infection in nursing mothers, especially if mastitis is recurring. Ductal cyst (ductal ectasia).
 Mondor disease, which causes thrombophlebitis of the breast's superficial veins and the anterior chest wall.


Laboratory Results 

Initial examinations (lab, imaging)
Mastitis is often diagnosed clinically. Rarely are labs required.
Consider the following in patients who are sick enough to require hospitalization:
Blood culture and CBC
 In cases of epidemic puerperal mastitis, milk leukocyte counts, milk cultures, and neonatal nasal cultures should be performed.
 If postpartum mastitis in a breastfeeding mother responds to antibiotic therapy, imaging is not necessary.
Breast ultrasonography is used to rule out abscess formation in women who feel a mass or fluctuation and should be given additional consideration if they have breast implants and have nonpuerperal mastitis.
Tests in the Future & Special Considerations
When compared to the unaffected side, the afflicted side of lactating moms produces saltier milk (greater Na and Cl contents). If you suspect MRSA, think about breast milk culture. As a possible initial presentation, consider testing for tuberculosis as well.
Diagnostic Techniques and Alternatives If the condition worsens and an abscess forms: The preferred diagnostic procedure for idiopathic granulomatous mastitis includes core needle aspiration, incision and drainage, excisional biopsy, and ultrasonography (US) guidance.

Management According to a Cochrane review, there is inadequate data to support or contradict the use of antibiotic medication in the treatment of lactational mastitis (4)[A]. If symptoms have been present for less than 24 hours and are mild, conservative care with milk withdrawal and supportive measures is advised.
Close surveillance or observation alone is a suitable nonsurgical treatment for people with early idiopathic granulomatous mastitis and mild symptoms or those worried about surgical scars.

General Actions 
Smoking cessation for individuals with periductal mastitis, including analgesics, warm compresses, and efficient, regular milk evacuation from the afflicted breast through nursing, pumping, or hand expressing

Medication Prioritized based on clinical severity of disease and possibility of MRSA as causative cause. 10 to 14 days of treatment.
 Antibiotics and drainage are typically effective treatments for localized infection and idiopathic granulomatous mastitis.
Initial Line
Outpatient - The most crucial management step is efficient milk removal.
- Cephalexin 500 mg QID or Dicloxacillin 500 mg QID
- Trimethoprim/sulfamethoxazole (TMP/SMX); DS BID (Consider MRSA if mastitis does not improve 48 hours after beginning first-line treatment.)
Doxycycline 100 mg BID; if clinical course lasts less than 3 weeks, investigate MRSA.
Inpatient - Nafcillin 2 g q4h, oxacillin 2 g q4h, or vancomycin 1 g q12h (MRSA probable) - Lactobacillus fermentum or Lactobacillus salivarius 9 log 10 CFU/day
- Daptomycin 1 g q24h Consider corticosteroids methotrexate (5)[A] if you have idiopathic granulomatous mastitis. When a patient is resistant to treatment with antibiotics, steroids, and methotrexate (6)[C], mycophenolate mofetil may be considered.
Use 1,200 mg of sunflower lecithin three to four times daily to avoid mastitis and recurrent plugs.

Child Safety Considerations
TMP/SMX administered to breastfeeding moms with mastitis can exacerbate neonatal jaundice.
Doxycycline treatment is limited to three weeks; prolonged therapy (lasting more than three to four weeks) is not advised because it may harm an infant's development cartilage, discolor their teeth, and upset their intestinal flora.
Next Line
Add metronidazole 500 mg TID IV or PO if the mastitis is odoriferous and confined under the areola. Add topical and oral nystatin if yeast infection is thought to be the cause of recurrent mastitis. Think about checking for yeast in milk and nipple tissue. The mother can also be considered for oral therapy.


Need for breast biopsy (suspected abscess or IGM) – Referral – Abscess creation

Warm compresses to increase blood flow and milk release and/or ice packs to relieve pain can be used as additional therapies on the injured breast.
Breast emptying may be facilitated by the use of a breast pump, particularly if the infant is unable to help.
Wear a bra that provides support but is not too tight.

Surgical Techniques 

The most efficient and quickest method for total eradication in cases of biopsy-proven idiopathic granulomatous mastitis is surgical removal. In comparison to surgery alone, the administration of steroids lowers the rate of remission and raises the rate of complete remission; NNT 3.84.

Alternative Therapies 

Breast lift technique for lymphatic breast drainage (may lessen engorgement and ease clogging) Cold cabbage leaf compress to be used twice day for up to 15 minutes. (Avoid applying cabbage leaves for an extended period of time or on a regular basis as this can reduce milk output.)
Use 1,200 mg of sunflower lecithin three to four times daily to avoid mastitis and recurrent plugs.

Admission 

 Rooming-in of the infant with the mother is strongly advised if a new mother is admitted to the hospital for treatment of her mastitis so that breastfeeding can continue.
In some hospitals, rooming-in may necessitate the infant's hospital hospitalization.
Admission requirements and initial stabilization Failure of outpatient oral therapy (patient unable to endure oral therapy, non-adherent to oral therapy, or suffering from a serious illness without access to necessary supporting care at home). Admission is also necessary for neonatal mastitis.
- Give out antibiotics.
- If breastfeeding, frequently empty the breasts.
- Administer pain relievers like acetaminophen or ibuprofen.
- Breastfeeding and breast pumping are recommended; place the infant and/or breast pump by the bed.
Start the baby off on feedings on the afflicted side.
Breastfeeding is not prohibited in cases of abscess drainage.
It may be helpful to massage the affected area from the blocked area toward the nipple, or to hold the baby at breast with the chin or nose pointing in the direction of the obstruction.
Patients must be afebrile and well-tolerated oral antibiotics in order to be discharged.


Patient Follow-Up Monitoring

Rest for nursing mothers, then go to the restroom. Enroll in the medical floor. Admit to an intermediate level of care or an intensive care unit if there are concerns about sepsis or hemodynamic instability.
 Following the remission of acute pathology, women over 40 should get a mammogram or ultrasound to rule out underlying breast cancer.

Encourage oral fluids in your diet.
 Vitamin A is present in multivitamins.


Modification of Lifestyle 
 Promote oral fluid intake. Sleep is crucial.
 Regular draining/emptying of both breasts when breastfeeding Preventing fissures on the nipples by caring for them with hypoallergenic nipple balm or just breastmilk
 The best latch results in the healthiest nipple/areola; if necessary, seek lactation professional assistance with latch.

Prognosis: Breast glands develop antibodies within the first few days of infection, which may provide protection against infection or reinfection. Puerperal - Good with prompt (within 24 hours of symptom onset) antibiotic treatment and breast emptying; 96% success rate. 11% risk of abscess if left untreated with antibiotics. Rare risk of abscess formation beyond 6 weeks postpartum if no recurrent mastitis. Idiopathic granulomatous mas

Complications 
breast infection 3% of women had puerperal mastitis, recurring mastitis with nursing following a subsequent pregnancy or upon resumption of breastfeeding, cessation of breastfeeding, bacteremia, or sepsis.