What is the next treatment step for a recurrent abscess on the back that has previously been drained and treated with doxycycline (doxy) and was susceptible to ciprofloxacin (cipro), now that the pus has reformed after completing a course of cipro?

From the Guidelines

The next treatment step for this recurrent abscess should be incision and drainage, followed by culture-guided antibiotic therapy, considering the possibility of MRSA coverage, as suggested by the Infectious Diseases Society of America guidelines 1. Given the recurrence of the abscess despite previous treatment with doxycycline and ciprofloxacin, to which the organism was susceptible, it's crucial to consider underlying conditions such as hidradenitis suppurativa, pilonidal cyst, or foreign material as potential causes for the recurrence, as recommended by the guidelines 1. Key considerations include:

• Incision and drainage of the abscess to prevent further accumulation of pus and to obtain cultures for antibiotic sensitivity testing.
• Starting antibiotic therapy that covers MRSA, such as trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 1-2 double-strength tablets (160mg/800mg) twice daily for 7-10 days, or clindamycin 300-450mg orally four times daily for 7-10 days, given the high likelihood of MRSA in recurrent abscesses.
• Daily chlorhexidine washes to the affected area to reduce bacterial colonization, as part of a broader strategy to manage and prevent recurrence.
• Referral to a surgeon or dermatologist if the abscess recurs again, for evaluation of underlying conditions and consideration of more definitive treatments such as excision of the abscess tract. The patient's history of recurrence despite appropriate antibiotic therapy suggests the need for a comprehensive approach that includes addressing potential underlying causes and ensuring adequate drainage and antibiotic coverage, as outlined in the guidelines 1.

From the Research

Treatment Options for Recurrent Abscess

The patient has a recurrent abscess on the back that has previously been drained and treated with doxycycline, and the culture was susceptible to ciprofloxacin. The pus has reformed after completing a course of ciprofloxacin. Considering the following treatment options:

• Re-drainage of the abscess may be necessary, as the pus has reformed despite antibiotic treatment 2.
• Alternative antibiotic therapy may be considered, as the current treatment with ciprofloxacin has not been effective in preventing recurrence 3, 4.
• Combination therapy with other antibiotics, such as clindamycin or trimethoprim-sulfamethoxazole, may be effective in treating the abscess, especially if it is caused by Staphylococcus aureus 5.

Key Considerations

When selecting a treatment option, consider the following:

• The patient's previous response to doxycycline and ciprofloxacin, as well as the susceptibility of the abscess culture to these antibiotics 2, 3.
• The potential for antibiotic resistance, particularly if the patient has been previously treated with antibiotics 3, 4.
• The need for prompt and effective treatment to prevent further complications, such as sepsis or spread of the infection 2, 6.

Potential Next Steps

Potential next steps in treatment may include:

• Re-drainage of the abscess, followed by antibiotic therapy with a different agent or combination of agents 2, 5.
• Switching to an alternative antibiotic, such as clindamycin or trimethoprim-sulfamethoxazole, if the abscess culture is susceptible to these agents 5.
• Considering combination therapy with multiple antibiotics, such as ciprofloxacin and metronidazole, as used in the treatment of liver abscess 6.