Tailoring treatment: breastfeeding patients
Question
You’re overrunning on your ward visit and as you try to leave the Sister asks you about a patient who was discharged last night with a prescription for oral cefalexin and metronidazole. The patient is breastfeeding her 1-month-old child and has rung the ward concerned about the risk posed to her infant having read the information leaflets. She has an intra-abdominal infection and has been prescribed cefalexin 500mg three times daily and metronidazole 400mg three times daily for 7 days. The Sister asks you to ring the patient directly with advice on whether it is safe to breastfeed her child while taking these antibiotics.
Outcome
Whilst you are on the ward you check the patient’s notes and establish that she has a history of rash with penicillins but has been able to tolerate cephalosporins in the past. Your hospital guidelines recommend co-amoxiclav as the first line oral option, with cefalexin and metronidazole as an alternative regime.
You drop into the Medicines Advice office on your way back from the ward to consult some specialist open access lactation resources including UKDILAS and Lactmed.
Outcome
Whilst you are on the ward you check the patient’s notes and establish that she has a history of rash with penicillins but has been able to tolerate cephalosporins in the past. Your hospital guidelines recommend co-amoxiclav as the first line oral option, with cefalexin and metronidazole as an alternative regime.
The manufacturer’s prescribing information for cefalexin advises that candidiasis and CNS toxicity may be a risk in a breastfed infant, as well as a later risk of sensitisation. For metronidazole the SmPC advises against its use whilst breastfeeding unless considered essential; in these circumstances the short, high-dosage regimens are not recommended.
You drop into the Medicines Advice office on your way back from the ward to consult some specialist open access lactation resources including UKDILAS and Lactmed.
These advise that the amount of cefalexin excreted into human milk is minimal and the risk to breastfed infants is low, with the exception of a single published case of an infant who developed gastrointestinal adverse effects. For metronidazole, you establish that although an increase in loose stools has been reported, short courses are considered compatible with breastfeeding, but infant monitoring is recommended. In addition, it has been suggested that metronidazole might make breast milk taste bitter, leading to poor feeding. This is largely anecdotal and not supported by published evidence.
Armed with your findings you ring the patient at home and firstly establish that the infant was born at term and is healthy. You then explain that the risks posed to her child are actually quite low and are probably outweighed by the benefits of continuing to breastfeed. Reassured by your advice, the patient decides that she wants to continue breastfeeding. You also counsel her on the side effects that her child might experience. Finally, you document your advice in the patient’s medical and nursing notes and speak to the Ward Sister.