Mammary Dysbiosis and Nipple Blebs Treated With Intravenous Daptomycin and Dalbavancin

Abstract

Introduction Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses. Main issue We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature. Management The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later. Conclusions We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus–positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

“…Proponents of the diagnosis of subacute mastitis or mammary dysbiosis apply the pathogenic microbiota model of breast inflammation to hypothesize that bacterial overgrowth or mammary dysbiosis creates sticky milk or biofilm, which causes plugging of ducts, indurated painful areas, decreased milk synthesis, pain with latch, and increased risk of mastitis. [87][88][89] Subacute mastitis or mammary dysbiosis has also been characterized as an inflammatory condition, which does not present with systemic illness or localized breast erythema. 90 Signs and symptoms attributed to subacute mastitis or mammary dysbiosis are detailed in Table 7.…”

“…Because of hypothesized bacterial biofilm formation, 2-6 weeks of treatment with antibiotics is typically recommended (cephalosporin, amoxicillin/clavulanate, or dicloxacillin, or erythromycin). 68,72,78,88,91 Some clinicians also hypothesize that women with symptoms of mammary dysbiosis are more likely to develop nipple blebs or white spots, proposing that white spots are distal extensions of biofilm. 72,87,88 The third article of this series also contests this pathogenic bacterial or biofilm hypothesis concerning aetiology of white spots.…”

Re-thinking lactation-related nipple pain and damage

“…Mitchell et al hypothesize that white spots result from subacute mastitis and mammary dysbiosis, in which ductal biofilm formation extends to the nipple epithelium ( Box 6 ). 79 , 80 Their hypothesis builds on the 2017 Rodriguez and Fernandez hypothesis that breast inflammation results from biofilm blockages within lactiferous ducts. 81 …”

“…In this analysis, the authors hypothesized that milk blebs are a surface extension of intra-ductal mammary dysbiosis and plugging caused by biofilm formation. 79 Mitchell et al propose that dysbiosis extends superficially to dissect the duct at the nipple orifice, resulting in growth of epidermal tissue over the orifice. (See the second article in this series for a critique of the diagnosis of mammary dysbiosis.…”

“…The authors assume that the white spots occluded nipple orifices but the case is more consistent with hyperkeratotic white spots rather than milk blisters. 79 In 2020, Mitchell and Johnson found that nipple 'blebs' represented 17% of all referrals to a US breastfeeding medicine practice. Thirtyfour women were treated for blebs, at the same time as the clinicians addressed milk supply that was in excess of the infant's needs, as deemed relevant.…”