How should I manage a patient with mastitis who is not responding to initial antibiotic therapy?

Management of mastitis not responding to initial antibiotic therapy:

• Confirm that the patient has taken the antibiotic correctly and completed the prescribed course, as infections should begin to respond within 48 hours and incomplete courses increase relapse risk.
• If symptoms persist beyond 48 hours, consider alternative diagnoses such as breast abscess or breast cancer, and refer to secondary care for further assessment.
• If an abscess is suspected, note that systemic symptoms like fever may have subsided due to antibiotics; imaging and specialist evaluation may be required.
• Send a sample of breast milk for microscopy, culture, and antibiotic sensitivity testing if not already done, to guide targeted antibiotic therapy.
• Prescribe a second-line antibiotic such as co-amoxiclav 500/125 mg three times daily for 10–14 days, adjusting treatment based on culture results.
• Consider the possibility of methicillin-resistant Staphylococcus aureus (MRSA), especially if first-line treatment fails and MRSA is locally prevalent or hospital-acquired; seek microbiologist advice for culture and sensitivity and alternative antibiotics.
• Identify and manage predisposing factors such as nipple damage, poor breastfeeding technique, or skin conditions that may facilitate bacterial entry.