Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and <i>Candida albicans</i> in breastfeeding women

Douglas, Pamela S.

doi:10.1177/17455065211031480

Cited by 13 publications

(24 citation statements)

References 69 publications

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“…Antifungals or antibiotics have not been demonstrated to resolve the symptoms of painful nipples and deep stabbing or radiating breast pain between breastfeeds, commonly diagnosed as mammary candidiasis or subacute mastitis. 17…”

Section: Blbi: ‘Subacute Mastitis’ or ‘Mammary Dysbiosis’mentioning

confidence: 99%

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

Douglas

2022

Womens Health (Lond Engl)

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Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

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Section: Blbi: ‘Subacute Mastitis’ or ‘Mammary Dysbiosis’mentioning

confidence: 99%

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

Douglas

2022

Womens Health (Lond Engl)

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“…The results shown in this and previous studies ( Tøndervik et al., 2014 ; Pritchard et al., 2017 ), together with the excellent safety profile and high tolerability of OligoG proven through clinical trials, (NCT02157922; NCT02453789; Van Koningsbruggen-Rietschel et al., 2020 ; Fischer et al., 2022 ), clearly demonstrate the clinical utility of the combination treatment (OligoG/nystatin) to treat biofilm-related candidal infections, especially those on in-dwelling silicone devices such as voice box prostheses and catheters, as an aid to increase device lifespan and reduce the risk of nosocomial infections (Nobile and Johnson, 2015; Andes et al., 2012 ; Eix and Nett, 2020 ). This study also highlights the possible role of OligoG in more appropriate management of other candidal-related infections currently being treated with nystatin alone, such as topical treatments for mastitis ( Douglas, 2021 ), skin infections, and oro-pharyngeal candidiasis ( Kojic and Darouiche, 2004 ; Pappas et al., 2004 ; Pappas et al., 2016 ) and also the prophylaxis and treatment of surgical/trauma ICU patients ( Giglio et al., 2012 ). In conclusion, non-toxic therapies such as OligoG, have significant potential for use alongside conventional antifungal treatments in the topical management of biofilm-related Candida infections.…”

Section: Discussionmentioning

confidence: 90%

Alginate oligosaccharides enhance the antifungal activity of nystatin against candidal biofilms

Powell

Adams

Quoraishi

et al. 2023

Front. Cell. Infect. Microbiol.

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BackgroundThe increasing prevalence of invasive fungal infections in immuno-compromised patients is a considerable cause of morbidity and mortality. With the rapid emergence of antifungal resistance and an inadequate pipeline of new therapies, novel treatment strategies are now urgently required.MethodsThe antifungal activity of the alginate oligosaccharide OligoG in conjunction with nystatin was tested against a range of Candida spp. (C. albicans, C. glabrata, C. parapsilosis, C. auris, C. tropicalis and C. dubliniensis), in both planktonic and biofilm assays, to determine its potential clinical utility to enhance the treatment of candidal infections. The effect of OligoG (0-6%) ± nystatin on Candida spp. was examined in minimum inhibitory concentration (MIC) and growth curve assays. Antifungal effects of OligoG and nystatin treatment on biofilm formation and disruption were characterized using confocal laser scanning microscopy (CLSM), scanning electron microscopy (SEM) and ATP cellular viability assays. Effects on the cell membrane were determined using permeability assays and transmission electron microscopy (TEM).ResultsMIC and growth curve assays demonstrated the synergistic effects of OligoG (0-6%) with nystatin, resulting in an up to 32-fold reduction in MIC, and a significant reduction in the growth of C. parapsilosis and C. auris (minimum significant difference = 0.2 and 0.12 respectively). CLSM and SEM imaging demonstrated that the combination treatment of OligoG (4%) with nystatin (1 µg/ml) resulted in significant inhibition of candidal biofilm formation on glass and clinical grade silicone surfaces (p < 0.001), with increased cell death (p < 0.0001). The ATP biofilm disruption assay demonstrated a significant reduction in cell viability with OligoG (4%) alone and the combined OligoG/nystatin (MIC value) treatment (p < 0.04) for all Candida strains tested. TEM studies revealed the combined OligoG/nystatin treatment induced structural reorganization of the Candida cell membrane, with increased permeability when compared to the untreated control (p < 0.001).ConclusionsAntimicrobial synergy between OligoG and nystatin against Candida spp. highlights the potential utility of this combination therapy in the prevention and topical treatment of candidal biofilm infections, to overcome the inherent tolerance of biofilm structures to antifungal agents.

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“…Healthy skin biofilms are strong and dynamic ecological structures created by dense network associations of bacteria and fungi, and integral to the host’s immune defence ( Appendix 1 ). 13 Antibiotics have been shown to destabilize the skin microbiome without altering the diversity or relative abundance of specific targeted species. This may explain why antimicrobial approaches which have proven so effective for internal infections have minimal efficacy against skin wound infections.…”

Section: Prevention and Management Of Lactation-related Nipple–areola...mentioning

confidence: 99%

“… 6 – 8 It is not surprising then, given the relative lack of research into clinical breastfeeding support, that overmedicalization and overtreatment is widespread in the care of breastfeeding women and their babies when inflammation, pain, and visible damage of the nipple–areolar complex emerge. 9 – 16 …”

Section: Introductionmentioning

confidence: 99%

Re-thinking lactation-related nipple pain and damage

Douglas

2022

Womens Health (Lond Engl)

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Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple–areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple–areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

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Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women

Cited by 13 publications

References 69 publications

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

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

Alginate oligosaccharides enhance the antifungal activity of nystatin against candidal biofilms

Re-thinking lactation-related nipple pain and damage

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