A case-control study of mastitis: nasal carriage of Staphylococcus aureus

Background Mastitis is a common problem for breastfeeding women. Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis in breastfeeding women. Methods The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis. Other factors such as infant nasal S. aureus carriage, nipple damage, maternal fatigue and oversupply of milk were also investigated. A case-control design was used. Women with mastitis (cases, n = 100) were recruited from two maternity hospitals in Melbourne, Australia (emergency departments, breastfeeding clinics and postnatal wards). Breastfeeding women without mastitis (controls, n = 99) were recruited from maternal and child health (community) centres and the rooms of a private obstetrician. Women completed a questionnaire and nasal specimens were collected from mother and baby and placed in charcoal transport medium. Women also collected a small sample of milk in a sterile jar. Results There was no difference between nasal carriage of S. aureus in breastfeeding women with mastitis (42/98, 43%) and control women (45/98, 46%). However, significantly more infants of mothers with mastitis were nasal carriers of S. aureus (72/88, 82%) than controls (52/93, 56%). The association was strong (adjusted OR 3.23, 95%CI 1.30, 8.27) after adjustment for the following confounding factors: income, private health insurance, difficulty with breastfeeding, nipple damage and tight bra. There was also a strong association between nipple damage and mastitis (adjusted OR 9.34, 95%CI 2.99, 29.20). Conclusion We found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. Mothers need good advice about optimal attachment of the baby to the breast and access to skilled help in the early postpartum days and weeks.


Background
Mastitis is a common problem for breastfeeding women [1][2][3] yet it is a poorly researched topic [4]. Mastitis may be a noninfective inflammation, resolving with heat and increased breast drainage [5,6], or an infective process which may lead to a breast abscess [7].
The most commonly isolated organism in lactating women with mastitis is Staphylococcus aureus (S. aureus): present in 32% to 44% of breast milk samples [8][9][10][11]. S. aureus is a commensal which may colonise the nostrils, axillae, vagina and pharynx of 30 to 50% of adults; as well as damaged skin, such as traumatised nipples of lactating women [12,13]. When S. aureus are present in the nostrils, they may act as a reservoir of S. aureus for clinical infections in the host or may facilitate spread to other people [14]. A review has concluded that four studies conducted in the 1990s found that S. aureus nasal carriers had a relative risk of 7.1 (95%CI 4.6, 11.0) of surgical-site infections, due to wound colonisation by the patient's endogenous flora [15].
Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis [16]. In clinical practice, there is anecdotal evidence that maternal or infant nasal carriage may be linked to recurrent mastitis in lactating women [17]. Our literature review did not identify any studies investigating the role of maternal or infant nasal carriage of S. aureus in mastitis. Medline searches (via PubMed) were conducted using keywords "staph* AND (lactation OR breastfeeding OR postpartum OR mastitis)" limited to human studies. A recent update (31 May 2006) has identified one case study of a mother of premature quadruplets who had symptoms of mastitis; methicillin-resistant S. aureus (MRSA) was isolated in expressed breast milk and nasal cultures from mother and infants [18].
We conducted a case-control study to examine the possible role of maternal nasal carriage of S. aureus in the development of mastitis. The role of S. aureus nasal carriage in the infant and other factors reputed to predispose women to mastitis, such as nipple damage, maternal fatigue and oversupply of milk, were also assessed.

Method
Cases were women with mastitis attending the Emergency Department or the Breastfeeding Clinic at the Royal Women's Hospital or Mercy Hospital for Women in Melbourne, Australia. Mastitis was defined as at least two breast signs or symptoms (pain, redness or lump) and one systemic symptom (fever or 'flu-like symptoms) present for at least twelve hours.
Women in the control group were lactating women (with babies aged six weeks or less) attending Maternal and Child Health (MCH) centres in metropolitan Melbourne (community clinics attended by new mothers). Also, women attending a private obstetrician for their six-week postnatal visit were invited to join the study.
After women gave written consent, they completed a questionnaire about nipple damage, oversupply of milk and other factors identified as possible predisposing factors for mastitis. Maternal fatigue was assessed using the four Vitality questions from the SF-36 [19]. (The SF-36 Health Survey is one of the most widely used health-related quality of life questionnaires, measuring eight health concepts, including Physical functioning, Social functioning and Vitality) [19]. At the end of the questionnaire for women with mastitis, participants were asked to describe "how you have been feeling and how mastitis has affected you"; the results of these open-text comments have been published separately [20].
Nasal specimens were collected from mother and baby. Saline-moistened swabs were rotated around the inside of the nasal vestibule, then placed in Amies charcoal transport medium. Women used a sterile water wipe to cleanse her nipple then expressed a small sample of milk in a sterile jar. Specimens were labelled and delivered to the microbiology laboratory at the Royal Children's Hospital, where the swabs were inoculated on Mannitol Salt Agar plates, a medium selective for staphylococci. An aliquot of expressed breast milk was also placed on a Mannitol Salt Agar plate. S. aureus was confirmed with DNase test (thermostable nuclease) and antibiotic susceptibility was conducted using standard microbiological methods.
Using Epi-Info 6.0 for an unmatched case-control study with 95% confidence and 80% power, if 20% of controls were nasal carriers and 40% of cases, we would need 91 women in each group. We planned to recruit 100 cases (women with mastitis) and 100 controls (women in the community). The data were analysed by Stata 8.0 computer program. The comparability of cases and control groups were described. Odds Ratios were calculated to compare exposures in each group, and Mantel-Haenszel Weighted Odds Ratios where appropriate. Logistic regression was used to determine factors predictive of mastitis.
Four infants over 6 weeks age were inadvertently recruited for the control group (two at 7 weeks, one 9 and one 11 weeks). A sensitivity analysis was conducted by repeating the analysis without these infants and the results were found to be almost identical: therefore the records of these four mothers and babies were retained in the sample.

Results
One hundred women with mastitis (cases) and ninetynine breastfeeding women (controls) were recruited between August 2002 and April 2004. Recruiting was stopped as the database incorrectly indicated that 100 controls had been recruited.
Fifty-four women with mastitis were recruited at the Mercy Hospital for Women and 46 women at the Royal Women's Hospital; from the breastfeeding clinics (n = 38), readmitted with mastitis in the wards (n = 32) and through the emergency departments (n = 25; 5 missing data). Most of the women for the control group were recruited through MCH centres (n = 70), whilst 29 women were from the private obstetrician.

Characteristics of study population
The background characteristics are displayed in Table 1. Women with mastitis were older than women in the control group (34 years and 32 years, p < 0.05), while the median age of the babies was 16 days for cases and 36 days for controls. Family income was lower in the women with mastitis and they were less likely to have private health insurance. Table 2 shows the health of women and their infants. After a question to determine if women had experienced mastitis in the past, women were asked "Have you ever had any other staph bacterial infections? For example: boils, abscesses, sores inside your nose?" Women with mastitis were more likely to have self-reported a past history of staphylococcal infection(s), 23% compared to 12%.
The sum of the scores from the four Vitality questions in the SF36 ranged from 4 (low) to 17 (high), with a mean of 10.7 (n = 195). Women were dichotomised into two groups scoring above or below the mean, and the groups compared. Sixty-one percent of women with mastitis scored below the mean vitality score, compared to 26% of controls. However, it is possible that some women were reporting lethargy associated with the onset of mastitis.
The breastfeeding characteristics of the sample can be seen in Table 3. Cases were more likely to have had nipple pain (71%) compared to controls (35%), and more likely to be *chi-square test for all analyses, except t-test for mother's and baby's age. **statistically significant. ns = not significant.
using purified lanolin on their nipples (64%) than controls (35%). Thirteen cases used topical antifungal cream/ ointment/gel, while nine controls used topical antifungal treatment (not significant). More cases used nipple shields (16%) than controls (2%). Cases were also more likely to have experienced breast engorgement in the previous week (51%) than controls (19%), were more likely to say that they had missed a feed (54%) than the controls  (36%) and that they had too much milk: 29% compared to 17%. Women were asked about pressure on their breasts in the previous week. More cases reported pressure from a tight bra (37%) than controls (20%).
Women with mastitis were more likely to report that their infant was having difficulty with breastfeeding, 57%, than the control group, 14%. Ten women with mastitis were currently feeding their infant expressed breast milk only, while none of the women in the control group was expressing only.

Microbiological results
There was no difference between nasal carriage of S. aureus in women with mastitis (43%) and women in the control group (46%) (

Summary of main findings and comparison with existing literature
The study showed that there was no difference in the proportion of women with mastitis and without mastitis who were nasal carriers (43% and 46% respectively). The over-all proportion of women with a positive nasal culture for S. aureus was 44.4% (95% CI 37.3, 51.6). This is consistent with the mean of 37.2% in general populations calculated by Kluytmans and colleagues from eighteen studies in 13,873 people [15], but seems higher than other studies published in 2004: 29% [22], 24% [23] and 33% [24].
We found that a very high proportion of infants of mothers with mastitis were nasal carriers: 82% and this was statistically significantly higher than infants of other women (56%). Infant nasal carriage remained significant after adjusting for other variables. Younger infants were most likely to be nasal carriers than older infants in this study. In a similar manner, Peacock and colleagues found that 40-50% of infants were colonised with S. aureus in the first eight weeks, falling to 21% by six months [25].
An association was not found between parity or a history of mastitis and being a case in this study, in contrast to previous studies [2,16]. This may be related to the high proportion of primiparous women in both groups of our study. Also, women with a history of mastitis may have been more likely to volunteer to be a control than other women.
The presence of a cracked nipple was associated with a high odds for mastitis, 9.34 (95%CI 2.99, 29.20), after adjusting for other factors. Foxman and colleagues also found an association with "nipple cracks or sores" with an OR of 3.4 (95%CI 2.04, 5.51) on logistic regression [16]. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. New mothers need good advice about optimal attachment of the baby to the breast  and access to skilled help in the early postpartum days and weeks.
This study found that using lanolin on nipples was significantly associated with mastitis on univariate analysis; however this was no longer significant on multivariate analysis. We expect that the association between creams on nipples and mastitis [26] is more likely to be related to the fact that nipple creams tend to be used when the nipples are damaged, and it is the nipple damage that probably is the route by which infection enters the breast rather than the creams themselves.
S. aureus was isolated in the milk of 46% of women with mastitis, a similar proportion to studies over the last thirty years [11]. S. aureus was also isolated in the milk of 17% of women without mastitis; mostly reported as "sparse" (11/15), probably reflecting contamination of the milk by bacteria on the skin of the nipple or the hands. In other studies between 0 and 20% of milk specimens from healthy women are positive for S. aureus [27,28].
Although it is not possible to conclude whether transmission occurred from the infant to the mother's breast or visa versa, it is likely that S. aureus was transmitted from the infant to the mother. In 1957, Wysham and colleagues demonstrated that 7 of 9 infants with positive throat cultures for S. aureus transmitted the organism to their bottle of formula milk [29]. Babies are born sterile and acquire their colonisation from their mother or the hands of health workers. Mothers and infants have been shown to be likely to carry the same strain of S. aureus [25,30]. Staphylococci may be transferred from the mother's nose to the infant's and then back to the mother's nipple, particularly if the nipple has been traumatised.

Strengths and limitations of this study
The diagnosis of mastitis relied on clinical signs and symptoms as there are no definitive tests for mastitis in women. The women in this study experienced either fever or systemic symptoms for at least 12 hours. Future studies could assess the usefulness of testing milk for the presence of leukocytes [31]. Molecular microbiology (eg pulsed field gel electrophoresis, PFGE) testing of isolates could have confirmed the clonality of S. aureus strains present in mothers with mastitis and in their infants. However, funding for this study was not sufficient to conduct PFGE.
It was originally planned to recruit women for the control group through MCH centres in the community (n = 25). However, we relied on women being referred to the study and recruitment was slow, so we started recruiting women Breastfeeding clinic) as we were seeking women without problems for the control group. Therefore the controls were more likely to be private patients than cases, which resulted in more women from the higher income group as controls than cases. In order to assess if this had an effect on the study results, a logistic regression model was developed using only women with private insurance and similar results were obtained as when the model included all women.
A limitation of the case-control design is that any associations identified cannot be concluded to be causal. For example, private health insurance appears to be protective against mastitis (OR 0.27, 95%CI 0.14, 0.51), but this association is due to the selection bias that occurred during recruitment. The association between nasal S. aureus carriage in infants and mastitis in their mothers (adjusted OR 3.19, 1.23, 8.29) appears to be robust as it was significant in each logistic regression model. However, it does not tell us if this association proves a link between nasal carriage and mastitis nor in which direction the transmission is occurring.

Implications for clinical practice and future research
Mastitis is an acute painful illness, not limited to the breast, and often associated with a negative emotional response [20]. In order to prevent mastitis, clinicians could advice new mothers about the factors commonly associated with this problem, such as milk stasis caused by missed feeds, expressing and breast restriction [32]. Breastfeeding women can be alert for the early symptoms of mastitis when they have been extra busy, for example when travelling or when they have visitors staying. If women have anticipatory guidance they can overcome milk stasis in these situations by increasing breastfeeds or expressing more frequently.
Future studies need to aim to collect clinical specimens prospectively in order to determine the transmission dynamics between mother and infant. Molecular microbiology (e.g. PFGE) can be used to confirm that the same strain of S. aureus is present in mother and child, and the direction of transmission of organisms between mother and child.
It is not standard practice for mothers to wash hands before breastfeeding (less than 50% of women in both groups "always" washed hands). Future studies could focus on hand washing as S. aureus may be carried transiently on the hands [33] and can then be transferred to the breast. Hospitals should be aware of the possibility of transmission of potential pathogens on breast pumps; dis-infection is particularly important after equipment is used by women with breast infections.
Another topic for future research is recurrent mastitis. Would it be possible to reduce recurrences of mastitis by reducing nasal carriage of S. aureus in mothers and infants where mothers have already experienced an episode of mastitis?

Conclusion
In conclusion, we found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis.