Good Morning all:  I have some questions regarding one of our clients
with recurrent mastitis.  I have her permission to post.  This is mom's
first baby, born March 3, 2008.  Gaining, growing beautifully.  Mom has
mastitis for the 3rd time now.  No recent history of nipple damage,
although she did have cracked nipples early post-partum.  First episode,
left breast:  Mar.29.  Admitted for IV abx, vancomycin, cephazolin,
followed by 10 days of oral keflex.  Nasal swab, nipple swab for MRSA
negative.  Second episode, both breasts:  May 9.  3 days of IV
cefuroxime at home, followed by 5 days of oral cephalexin.(keflex).
Third episode, right breast, May 29.  Started oral keflex, initially
double dose for a few days in an attempt to avoid IV abx.   To remain on
this for 3-4 weeks. So far is responding to medication. So far no
yeast!, although she has had it, and knows what to watch for.  All
episodes accompanied by chills, flu-like symptoms, and very high temps
over 39 C (102F)  
 
Further information:  Mom is  Group B Strep pos.  Was very ill with
toxic shock as a teen (about 10 years ago).  Tends to be anemic, is
being treated for this, hasn't had blood checked for a while.  Is on
Zoloft, for hx of depression.  Has a very generous milk supply, almost
an over supply, breasts always feel full.(does not pump)  
 
My questions are:  Could the GBS be a factor in recurring mastitis?  Are
the abx she is taking effective, if this is the case?   Should we ask
for culture of the milk, and not just the nipples?  If MRSA is present,
would it be in the milk but not on her nipples?   Could the Zoloft be
contributing to oversupply (TOXNET/LACTMED states "Sertraline has caused
galactorrhea in nonpregnant, nonnursing patients.[13][14] The clinical
relevance of these findings in nursing mothers is not known") 
 
With assistance from the lactnet archives, these are some of the
suggestions I have given her:
1)  culture everyone else in the home, (baby and dad, no pets) to check
if they are carrying staph
2)  recheck hgb levels
3)  ask to have her milk cultured
4)  consider stopping Zoloft, and see if milk production slows down a
bit (was off med during pregnancy, no problems)
5)  osteopathic breast manipulation
6)  naturopath  
 
I am also wondering about the recent reference in the archives to the
use of rifampin in conjunction with abx, to improve efficacy.  Has that
been published yet?  Does anyone have any more info about this?  I
believe that I read that it was team Hartmann that studied this, in
which case I'm in luck, as they are here in Toronto on June 4 for a
conference which I'm attending.
 
I've tried to be brief, but can provide more info if necessary.  Thanks
in advance for any ideas or suggestions you may have.  
Doreen Vanderstoep, RN, IBCLC Ontario, Canada, 
 

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