>Do you always recommend
>antibiotics for a br. infection?  Do you mention the risk of yeast from
>anti.b. use?  Have you weighed the risk of abscess against the risk of
>yeast?  Where have you settled?

Pat Gima, these are very hard questions! This is part of an answer I wrote
previously about mastitis:

>Someone asked about the systemic symptoms associated with mastitis - how
>they can come on so quickly.
>I explain to people that the symptoms of lethargy, aching, headache and even
>fever are caused by "milk fever". Milk that is banking up in the breast
>leaks out into the bloodstream and this leads to an inflamatory reaction
>around the body.
>Many years ago, Mavis Gunther, recognised the similarity of the fever of
>mastitis to the effects of an incompatible blood transfusion (Acute
>mastitis, The Lancet, Jan 28, 1956, 175-180).
>Maureen Minchin (Breastfeeding Matters) stresses that mastitis is not
>necessarily a bacterial infection: it means an inflamation of the breast.
>We still don't have an easy way of determining when a bacterial infection is
>present and antibiotics are needed.
>

In practice, I will usually give women a script for an appropriate
antibiotic (like flucloxacillin 500mg qid), and give lots of advice about
draining the affected breast. If she can see an improvement then she may not
need the antibiotic. If her symptoms are not improving after 12 or 24 hours,
she needs to start it (and finish the course). We can't generalise and say
we don't ever need  antibiotics for mastitis, but we can give other advice
as well and not commence antibiotics at the first sign of redness or symptom
of aching, and so on.

If someone has a history of thrush infections, I would probably prescribe
nystatin caps ii qid to take with the antibiotics. But usually, I just
mention that if she notices burning nipples or shooting breast pain, or
thrush in the baby, to let me know.

I give people a handout on mastitis that mentions both abscess and thrush as
possible complications of mastitis. I only mention abscesses if the mastitis
is not resolving, and she needs a second course of antibiotics. But still
the vast majority of episodes of mastitis don't end up as abscesses. (I've
just realised that I've onlyt seen one abscess in the last 12 months - and
will probably see 3 in the next month :-).)

Lisa Amir
GP / LC in Melbourne, Australia.