Pediatric emergency medicine trisk 0416 0416

The clinical presentation of neonatal breast infection is characterized by local
signs of inflammation, such as edema, erythema, and warmth. Fever is present in
just 22% to 38% of cases. Traditionally, the evaluation of even well-appearing
infants with neonatal mastitis included blood, urine, and potentially CSF cultures;
however, there is scant evidence supporting this degree of diagnostic workup.
There is growing evidence that demonstrates little correlation between blood,
urine, or CSF cultures and causative organisms of mastitis or breast abscess.
Therefore, for well-appearing infants with localized mastitis, one may consider
culture of purulent discharge, if present, and forgoing further evaluation for
invasive infection. Empiric antibiotic coverage for S. aureus including CAMRSA active agents should be initiated. Infants managed as outpatients require
strict return precautions and close follow-up with PCP. Although uncommon in
neonatal mastitis, infants with signs of systemic illness have potential for invasive
infections, including bacteremia, osteomyelitis, and pneumonia. Therefore, a
complete sepsis evaluation is indicated. For hospitalized infants, initial ED
therapy consists of empiric broad-spectrum intravenous antibiotic for S. aureus ,
streptococcal organisms, and gram-negative enterics. These antibiotic regimens
include vancomycin plus a third-generation cephalosporins for gram-negative
coverage. Subsequent antibiotic therapy is guided by culture and sensitivity
results. If there is concern for breast abscess, incision and drainage should be
done by a surgeon to minimize harm to developing breast tissue.
Breast infection in postpubertal females is classified as lactational or
nonlactational. Nonlactational mastitis/breast abscess is rare but can develop in
the central or peripheral regions of the breast from introduction of skin bacteria
into the ductal system. Infections in the central region of breast, proximal to the
nipple, are more likely in the setting of obesity, nipple piercings, or poor hygiene,
while peripheral mastitis is more likely to be associated with trauma or systemic
illness. Other predisposing factors for mastitis include previous radiation therapy,
foreign body, sebaceous cysts, hidradenitis suppurativa, and trauma to the
periareolar area. Signs and symptoms of infection include local erythema,
warmth, pain, and tenderness and purulent nipple discharge. Systemic signs,
including fever, are less commonly present. Organisms commonly implicated in

this age group include both methicillin-sensitive and resistant S. aureus,
streptococcal species, Enterococcus, Pseudomonas species, and anaerobic
organisms such as Bacteroides species.
Recommended treatment for mastitis in the postpubertal female includes
initiation of anti-staphylococcal oral antibiotic therapy and warm compresses.
Instruct patients to keep the area clean and dry, to wear a clean cotton bra, and to