Prescribing antibiotics for women with mastitis

Morgan Liotta

6/05/2021 2:47:54 PM

One expert is examining how GPs make decisions about treating mastitis, as well as their experience using clinical guidelines.

Woman breastfeeding
There is currently limited research about how doctors make decisions when prescribing antibiotics for breastfeeding women.

Mastitis, or breast infection, is a common issue for breastfeeding women. Around one in five experience it during the first six months after giving birth, and most will visit their GP for advice.
Current guidelines from Melbourne’s Royal Women’s Hospital (RWH) on prescribing antibiotics for mastitis align with the Therapeutic Guidelines, and vary according to symptoms and stages.
If women get symptoms of mastitis during the early postpartum period and they have nipple damage, it is likely to be a breast infection with Staphylococcus aureus, and it is recommended to start antibiotics immediately.
If women get symptoms later (for example, once their baby is sleeping through the night) – such as painful breast, hard or red area of the breast, feeling unwell – general measures are recommended to begin with. These include feeding or expressing more frequently, applying cold to the breast to reduce swelling, and taking analgesia such as ibuprofen.
If there is no improvement after 24 hours, it is recommended to start antibiotics.
According to one expert, however, it is unclear to what extent Australian GPs are following these guidelines, or how they make decisions on prescribing medications for treating breastfeeding women with mastitis.
‘In practice, GPs would usually prescribe an antibiotic and either start immediately, if the patient is very unwell or has nipple damage, or try the steps [as advised by the Therapeutic Guidelines] and start antibiotics later if no improvement,’ Women’s health GP, La Trobe University Professor and RWH breastfeeding specialist, Lisa Amir, told newsGP.
Advice about antibiotic use has changed over the years for some infections, according to Professor Amir, but has remained ‘pretty consistent’ for the antibiotic treatment of mastitis.
‘Yet I occasionally hear of breastfeeding women prescribed antibiotics outside the guidelines for mastitis,’ she said.
Professor Amir has had an interest in mastitis since another woman in her new mother’s group in the 1980s was given incorrect advice to stop breastfeeding when she had mastitis.
‘I am interested in understanding how GPs make decisions about treating mastitis and what they think about using guidelines, in particular the Therapeutic Guidelines,’ she said.
This led Professor Amir to embark on her research project with La Trobe University, ‘Understanding antibiotic prescribing for mastitis in breastfeeding women: A mixed-method study’, for which she received a 2020 Therapeutic Guidelines Limited (TGL) / RACGP Foundation Research Grant.
The project is a mixed-method approach designed to enable an understanding of Australian GPs’ current practices when caring for women with mastitis. It includes general practice data using the NPS MedicineInsight database.
The Foundation Grant will also enable interstate collaboration with South Australia’s Flinders University by providing funding for a data analyst to use the dataset to describe management of mastitis in general practice.
‘Currently, we have little research about how doctors make decisions when prescribing for breastfeeding women,’ Professor Amir said.
‘How do they weigh up the risks and benefits?’
The research team is examining how GPs prescribe and their use of guidelines, with the hope the findings will provide evidence to support improvements in the guidelines and education for health professionals in the future.
‘Improving the management of this common breastfeeding problem for new mothers will ensure fewer complications, like breast abscess development or hospital admission, and better mental and physical health for mothers and their children,’ Professor Amir said.
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Dr Michael Lucas Bailey   7/05/2021 6:51:38 AM

“Therapeutic Guidelines” is a commercial entity and that they are sponsoring this research is a conflict of interest. Not all GPs have access to Therapeutic Guidelines and there are other guidelines available too, Dynamed, eMedicine/Medscape and UpToDate are some. At the end of the day they are all still guidelines too. Isn’t evidence based medicine supposed to place journals, such as those available through PubMed, higher than guidelines? How much of our clinical decision making and critical thinking are we pushing aside in preference to a commercial entity?

Dr Denis James Carragher   7/05/2021 9:57:51 AM

Very good comments by Dr Bailey. My consideration is with regard to late onset mastitis the "guidelines" recommendation requires two visits, expensive in time and cost. Finally Dr Bailey's comment about guidelines is so very true, I have seen some shockers applied without thought.

Dr Elizabeth Kate Marles   7/05/2021 3:43:48 PM

As the Chair of Therapeutic Guidelines, I think it is important to correct Dr Baileys comments above. Therapeutic Guidelines is an Australian not-for-profit organisation that exists to support doctors in getting the best outcomes for their patients (unlike Dynamed and UpToDate, which are for-profit American companies). Because it’s impossible for doctors to read all the primary research, Therapeutic Guidelines teams up with Australian experts to distil the advice for the point of care. It’s important that the recommendations are completely independent, and the only way to achieve this is for funding to come directly from the community (rather than government or pharma). Therapeutic Guidelines partners with the RACGP to provide grants for general practice researchers but it does not commission research. Therapeutic Guidelines is committed to responding to all user feedback, to make sure advice isn’t just evidence but practical as well