Information about topical Bactroban (mupiricin) use for nipple trauma

Question:
I am a Public Health Nurse working to support breastfeeding families. A physician has asked for information about topical Bactroban (mupiricin)  use for nipple trauma. I shared information about this drug from Thomas Hale’s, Medication and Mother’s Milk. Are there any additional  research/articles regarding Bactroban that I can reference?

Also, I am familiar with the All Purpose Nipple Ointment (APNO), however, in a situation where the all purpose nipple ointment does not seem to be effective, might there be an advantage to trying Bactroban on its own?

Susie Wood BN RN
Public Health Nurse, IBCLC

Answer:
Dear Susie,
How nice to hear from you and thanks for the kind works.  Hope I can help you with your present concerns.

I would advise you to go to the website of the Academy of Breastfeeding Medicine(  http://www.bfmed.org/ ) to review their Mastitis and Sore Nipple protocols. Because they are written by physicians and are evidence-based, these protocols carry great weight with other medical providers.

As Hale points out in Medications and Mothers Milk 2008, a benefit of mupiricin (Bactroban) is that it is a poorly metabolized (hence safe-to-ingest) topical antibacterial ointment that is effective against regular staph and MRSA.  However, be advised that topical treatment  doesn’t help if the mother already has mastitis.

A good article to review on the subject of non-healing sore nipples is:  Livingstone V, et al. The treatment of Staphylococcus aureus infected sore nipples:  a randomized comparative study, Journal of Hum Lact 1999; 15(3):214.) These authors present evidence that once a mom develops ascending staph infection from nipple cracks, she needs an oral antibiotic. Bactroban may prevent some, but not eradicate such infections once established.

You can make only limited claims for topical antibiotic nipple creams, but they can be part of the first aid treatment for broken skin in highly pathogen-rich environments.  The first aid for any skin wound is to keep cracks clean, and to apply topical antibiotic cream if indicated.  HCPS must still closely monitor healing.  Any crack anywhere else on the body that doesn’t heal promptly is presumed to be colonized if not infected.  Pathogens form biofilms that may make it difficult for topicals to penetrate to the wound bed.  Biofilms are a kind of saran-wrap-like film that pathogens grow to protect themselves.  Baby saliva promotes formation of biofilms according to Hale and others.  A new article describes biofilm development, colonization with various strains of staphylococcus organisms, and mupiricin resistance in women with mastitis.  That reference is  Delgado S, et al.  Staphylococcus epidermidis strains isolated from breast milk of women suffering infectious mastitis:  potential virulence traits and resistance to antibiotics,  BMC Microbiology 2009; 9:82 (http://biomedcentral.com/1471-2180/82 )

Always keep in mind that non-healing nipple wounds can be a marker for subclinical mastitis, and postpartum women are included in at-risk groups for MRSA.  PubMed searches using the search words:  “mastitis, MRSA, staph aureus, cracked nipples”  will yield a wealth of articles on the subject.

Hale’s newly published article in Breastfeeding Medicine casts doubt on the existence of “ductal yeast”.  In the absence of diagnosed thrush in the infant, it is doubtful that cracked nipples in the early postpartum have relationship to  “yeast”.  So why use an antifungal?  The cortisone in the cream is also a concern.  The tendency is for moms to self-treat sore nipples and even mastitis for lengthy periods of time. Hence, APNO cream may contribute to over-ingestion of cortisone.  The single-ingredient approach of Bactroban is another thing to recommend it.

Finally, I instruct mothers that sore nipple treatment should result in prompt resolution of symptoms (in about 3 days.)  If the nipples still don’t heal, the mother should report back to the MD for more evaluation as per the ABM protocols.

Barbara Wilson-Clay, BSEd, IBCLC, FILCA