What antibiotics are used to treat an infected pilonidal cyst?

Antibiotic Treatment for Infected Pilonidal Cysts

For infected pilonidal cysts, broad-spectrum antibiotics covering both aerobic and anaerobic organisms should be used, with clindamycin plus either ciprofloxacin or levofloxacin being the preferred regimen for outpatient treatment. 1

First-Line Treatment Approach

Initial Management

• Primary treatment: Incision and drainage of the abscess is the cornerstone of management
• Antibiotic selection: Following drainage, antibiotics should be initiated:
  • Outpatient regimen:
    • Clindamycin 300-450 mg orally every 8 hours PLUS
    • Ciprofloxacin 750 mg orally every 12 hours OR Levofloxacin 750 mg orally every 24 hours 1
  • Inpatient regimen (for severe infections):
    • Metronidazole 500 mg IV every 8 hours PLUS
    • Ciprofloxacin 400 mg IV every 12 hours OR Levofloxacin 750 mg IV every 24 hours OR Ceftriaxone 1 g IV every 24 hours 1

Duration of Treatment

• Standard course: 5-7 days, but should be extended if infection has not improved within this period 1
• Treatment should continue until clinical improvement is observed

Alternative Antibiotic Options

For patients with penicillin allergy or when first-line treatments fail:

• Cephalexin 500 mg orally four times daily plus metronidazole 500 mg orally three times daily 2
• Trimethoprim-sulfamethoxazole (TMP-SMX) for suspected MRSA coverage
• Doxycycline 100 mg twice daily as another MRSA option

Special Considerations

Severe Infections

For patients with systemic inflammatory response syndrome (SIRS), immunocompromise, or extensive infection:

• Broader coverage is recommended: Vancomycin plus piperacillin-tazobactam or a carbapenem 1
• Hospitalization should be considered for these patients 1

Surgical Management

• Aspiration under local anesthesia followed by antibiotics may be effective in selected patients (83% success rate) 2
• For recurrent pilonidal abscesses, complete excision of the underlying cyst is recommended once acute inflammation resolves 3

Follow-Up Care

• Re-evaluate within 48-72 hours to assess response to treatment
• Patients should be monitored for complications such as:
  • Spread of infection to adjacent structures
  • Systemic infection
  • Recurrence (14% with primary closure vs. lower with secondary healing) 3
  • Fistula formation

Prevention of Recurrence

• Address predisposing factors such as excessive hair in the sacrococcygeal region
• Good hygiene practices
• Consider definitive surgical treatment (complete excision) after resolution of acute infection to prevent recurrence

Pitfalls to Avoid

• Don't rely on antibiotics alone: Drainage is essential for proper treatment of pilonidal abscesses
• Don't use narrow-spectrum antibiotics: Coverage for both aerobic and anaerobic organisms is necessary
• Don't delay surgical consultation: For extensive or recurrent disease, early surgical evaluation is crucial
• Don't overlook MRSA coverage: Consider adding MRSA coverage in patients with risk factors or prior MRSA infections

Proper management of infected pilonidal cysts requires both appropriate surgical drainage and targeted antibiotic therapy to effectively resolve the infection and prevent complications.