Interventions for preventing mastitis after childbirth

Puerperal mastitis caused by limited community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) clones

Objective

To outline the epidemiology of puerperal mastitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and evaluate the effect of an infection control bundle on its incidence.

Methods

A surge in MRSA puerperal mastitis was noted in a community hospital in September 2009. MRSA samples from mastitis cases and the environment underwent typing using multilocus sequence typing (MLST), staphylococcal cassette chromosome mec (SCCmec), gene encoding surface protein A (spa), accessory gene regulator (agr), and pulsed-field gel electrophoresis (PFGE). The phenotypic characteristics, including superantigen toxin profiles, gene encoding Panton-Valentine leucocidin (pvl), and minimal inhibitory concentration (MIC) against vancomycin, were ascertained. Subsequently, an infection control bundle emphasizing contact precautions was introduced, and mastitis incidence rates pre- and post-intervention were compared.

Results

The majority of cases occurred within 6 weeks post-delivery in first-time mothers. Of the 42 S. aureus isolates (27 from mastitis and 15 from colonized staff and environmental sources), 25 (92.6%) clinical and 3 (20%) colonized MRSA were identified as ST59-SCCmecVT-spa t437-agr group I with a vancomycin MIC of 1 mg/L, pvl-positive, and predominantly with a consistent toxin profile (seb-selk-selr). PFGE revealed 13 patterns; pulsotype B exhibited clonal relatedness between two clinical and three colonized MRSA samples. Post-intervention, the incidence of both mastitis and MRSA mastitis notably decreased from 13.01 to 1.78 and from 3.70 to 0.99 episodes per 100 deliveries, respectively.

Conclusion

Distinct community-associated MRSA (CA-MRSA) clones were detected among puerperal mastitis patients and colonized staff. The outbreak was effectively controlled following the implementation of a targeted infection control bundle.

Probiotics and human lactational mastitis: A scoping review

PROBLEM

Lactational mastitis is a common condition amongst breastfeeding women. It is associated with decreased breastfeeding rates and often treated with antibiotics.

BACKGROUND

The anti-inflammatory effects of probiotics have been identified as a potential treatment or prevention strategy for lactational mastitis leading to increased commercial and public interest. Despite the marketing of probiotics to women, evidence is still emerging as to its efficacy.

AIM/METHODS

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to identify and examine the evidence around probiotic consumption and lactational mastitis. The review addressed the question; what is the evidence regarding probiotic consumption and human lactational mastitis? Studies were critically appraised using the Joanna Briggs Institute checklist for randomised control trials (RCTs).

FINDINGS

Five RCTs met the inclusion criteria; three concerned probiotic consumption for the treatment of mastitis, two for the prevention of mastitis. All reported a lower incidence of mastitis in the probiotic groups.

DISCUSSION

Although potentially promising results were reported across all studies there were significant methodological limitations concerning; appropriately described baseline characteristics, study hypotheses, lack of power calculations, definitional issues, and potential conflicts of interest.

CONCLUSION

Probiotics may have utility for the treatment or prevention of lactational mastitis. However only a few studies with significant limitations have been published to date. Well designed and conducted studies are needed before evidence-based recommendations can be made for use of probiotics in the treatment or prevention of lactational mastitis.

Management of Common Breastfeeding Problems

The U.S. Department of Health and Human Services Healthy People 2020 goal is to achieve a rate of breastfeeding at 12 months of age of 34.1%. Primary care providers are the first line in breastfeeding—from prenatal nipple evaluations to identifying and treating complications early. Breastfeeding conveys numerous benefits for both infant and mother. Currently, 77% of women attempt breastfeeding, but only 16% are still breastfeeding at 12 months of age. One of the top reasons for failure is lack of provider support when faced with breastfeeding problems. When the diagnosis is missed, complications can include hospitalization and cessation of breastfeeding. Understanding and being able to manage complications as well as having a team care approach involving an IBCLC and support group, such as La Leche League, are crucial in ensuring breastfeeding success.

Antibiotics for mastitis in breastfeeding women

BACKGROUND

Mastitis can be caused by ineffective positioning of the baby at the breast or restricted feeding. Infective mastitis is commonly caused by Staphylococcus aureus. The prevalence of mastitis in breastfeeding women may reach 33%. Effective milk removal, pain medication and antibiotic therapy have been the mainstays of treatment.

OBJECTIVES

This review aims to examine the effectiveness of antibiotic therapies in relieving symptoms for breastfeeding women with mastitis with or without laboratory investigation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012), contacted investigators and other content experts known to us for unpublished trials and scanned the reference lists of retrieved articles.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs comparing the effectiveness of various types of antibiotic therapies or antibiotic therapy versus alternative therapies for the treatment of mastitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When in dispute, we consulted a third author.

MAIN RESULTS

Two trials met the inclusion criteria. One small trial (n = 25) compared amoxicillin with cephradine and found no significant difference between the two antibiotics in terms of symptom relief and abscess formation. Another, older study compared breast emptying alone as 'supportive therapy' versus antibiotic therapy plus supportive therapy, and no therapy. The findings of the latter study suggested faster clearance of symptoms for women using antibiotics, although the study design was problematic.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis. There is an urgent need to conduct high-quality, double-blinded RCTs to determine whether antibiotics should be used in this common postpartum condition.

Health professionals' advice for breastfeeding problems: not good enough!

Jane Scott and colleagues have recently published a paper in the International Breastfeeding Journal showing that health professionals are still giving harmful advice to women with mastitis. We see the management of mastitis as an illustration of health professionals' management of wider breastfeeding issues. If health professionals don't know how to manage this common problem, how can they be expected to manage less common conditions such as a breast abscess or nipple/breast candidiasis? There is an urgent need for more clinical research into breastfeeding problems and to improve the education of health professionals to enable them to promote breastfeeding and support breastfeeding women.