A 25-year-old woman, gravida 1 para 1, comes to the office for evaluation of fever and right breast pain. The patient is 2 weeks postpartum after an uncomplicated pregnancy and vaginal delivery. She has been breastfeeding every 2-3 hours; however, the infant has had difficulty with latching due to the mother's inverted nipples. Yesterday, the patient developed constant sharp pain in the side of her right breast as well as fever, chills, nausea, and body aches. The pain is worsening, especially during breastfeeding. She has been taking acetaminophen and ibuprofen with minimal relief. The patient has no chronic medical conditions. She is on maternity leave from her engineering job. The patient has no drug allergies and is taking a daily prenatal vitamin. Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 100/min. Examination reveals the upper outer quadrant of the right breast to be erythematous, tender, and swollen but without fluctuance. The left breast has no erythema or tenderness.
Which of the following is the best next step in management of this patient?

Question

A 25-year-old woman, gravida 1 para 1, comes to the office for evaluation of fever and right breast pain.  The patient is 2 weeks postpartum after an uncomplicated pregnancy and vaginal delivery.  She has been breastfeeding every 2-3 hours; however, the infant has had difficulty with latching due to the mother's inverted nipples.  Yesterday, the patient developed constant sharp pain in the side of her right breast as well as fever, chills, nausea, and body aches.  The pain is worsening, especially during breastfeeding.  She has been taking acetaminophen and ibuprofen with minimal relief.  The patient has no chronic medical conditions.  She is on maternity leave from her engineering job.  The patient has no drug allergies and is taking a daily prenatal vitamin.  Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 100/min.  Examination reveals the upper outer quadrant of the right breast to be erythematous, tender, and swollen but without fluctuance.  The left breast has no erythema or tenderness. 
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf89_0132_8f63_83a26d5ec53b_MD0005_00 This patient has fever, breast pain, and focal inflammation, which are classic for lactational mastitis. Women are at greatest risk of developing mastitis during the first 3 months postpartum, when breastfeeding is still becoming established. Difficulties with breastfeeding (eg, poor latching) can lead to prolonged engorgement, inadequate milk drainage, and clogged milk ducts (tender, palpable lump or "cord"). Bacteria from the skin can enter the milk ducts and proliferate in stagnant milk, resulting in infection. The most common organism is Staphylococcus aureus. Diagnosis is clinical and no further workup is indicated. First-line antibiotics include oral dicloxacillin (antistaphylococcal penicillin) and cephalexin (first-generation cephalosporin); both are safe during breastfeeding. (Choice A) Intravenous ampicillin is a second-generation penicillin used for intrapartum prophylaxis of Group B Streptococcus colonization. Ampicillin has no activity against S aureus. (Choice B) Intravenous vancomycin is the treatment of choice for suspected methicillin-resistant S aureus (MRSA). It is indicated in the treatment of lactational mastitis in patients who have MRSA risk factors (eg, recurrent hospitalizations/antibiotics, incarceration), hemodynamic instability, or failed outpatient therapy. (Choice D) Cold compresses, nonsteroidal anti-inflammatory medication, and breast pumping are first-line treatments of breast engorgement, which typically presents with diffuse, bilateral breast tenderness. (Choice E) Trimethoprim-sulfamethoxazole is effective against S aureus. However, it is avoided during breastfeeding as it is excreted in breast milk and is associated with a risk of neonatal kernicterus. Educational objective: Lactational mastitis typically occurs during the first 3 months postpartum and presents with fever, breast pain, and focal inflammation. First-line antibiotics include oral dicloxacillin and cephalexin. References: Breast pain: engorgement, nipple pain, and mastitis. (http://www.ncbi.nlm.nih.gov/pubmed/26512442) Management of mastitis in breastfeeding women. (http://www.ncbi.nlm.nih.gov/pubmed/18819238)

A 25-Year-Old Woman, Gravida 1 Para 1, Comes to the Office