This is to the thread on persistent nipple pain despite several rounds of
treatment for presumed yeast, and the difficulty of getting positive
cultures from milk.
When I culture on suspicion of yeast or bacterial infection of the nipples,
I don't do a milk culture.  I use sterile saline solution on a dry culture
swab and roll it over the skin or skin lesion where the woman is feeling the
most pain.  When the lesions look purulent and wet they tend to grow staph
aureus, and rarely it will be a strain that is penicillin sensitive, but
mostly they need erythromycin or dicloxacillin.  However, all but one of the
staph positive cultures I have seen, have shown a bacterium sensitive to
fucidin which is a topical agent in salve available here and if there are no
systemic symptoms I have good results treating the lesions topically only.
I have had several cultures unequivocally positive for yeast, and the best
thing was that I suspected yeast in all those cases.  There were either no
lesions but intense pain/burning not always related to feeding, or cracks at
the nipple base, where nipple protrudes from areola.  At least one of these
also cultured positive for staph.  I have seen negative cultures for staph
too, and those lesions appeared to be simple mechanical damage, without an
inflammatory response.

I second all those who advise doing a culture in the case in question.  If
the condition is not responding to the most powerful treatment available for
the presumed problem, maybe the presumption is mistaken.  I would suspect
bacteria, either in addition to the yeast or simply instead of it.

The most painful lesions I have ever encountered were bacterial.  That
mother had 'had to quit breastfeeding' because of the same problem with her
previous child.  On closer questioning it turned out she had breastfed for 8
months with excruciatingly painful and frequently bleeding sores on both
nipples the entire time!  I thought of Pamela Morrison's accounts of how
African mothers get the same problems as European or US women, they just
persist more steadfastly at BF - this mother was from a country on the
southern part of the African continent.  She didn't even volunteer the
information that she was sore; she came back for her baby's PKU test and it
wasn't until I asked if she was having any pain that she told me about it.
It was so bad that she cried from when the baby latched until he was
finished - and yet she never considered not breastfeeding.  Her positioning
was sub-optimal as well, but because she didn't complain, she had never
gotten any help before, either.  To say that this was humbling is putting it
mildly.  I have seldom met anyone more grateful when her sores cleared after
about one week of treatment with an antibacterial salve plus cortisone
salve, and a small adjustment in baby's latch.

At this point I feel more confident about my clinical judgment because I
have the opportunity to do cultures and I see a correlation between certain
kinds of lesions or soreness, and certain microbes on culture.  If you don't
have the option of culturing, consider an attempt with Jack Newman's
three-pronged approach, against yeast, bacteria and inflammation (all
purpose nipple ointment, APNO).  Sometimes getting something that works is
more important than figuring out which bug is the villain.

Rachel Myr
Kristiansand, Norway

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