What is the best antibiotic (abx) for a draining pilonidal cyst?

Management of Draining Pilonidal Cysts: Antibiotic Selection

For draining pilonidal cysts, the recommended first-line antibiotic therapy is clindamycin 300-450 mg orally three times daily plus trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily). 1

Initial Management Approach

• Incision and drainage is the primary treatment for inflamed pilonidal cysts and abscesses, with antibiotics added based on presence of systemic inflammatory response syndrome (SIRS) 1
• Antibiotic therapy should be targeted at the most common pathogens involved in skin and soft tissue infections, particularly those found in the perineal region 2, 1

Antibiotic Recommendations

First-line options:

• Clindamycin 300-450 mg orally three times daily plus trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily) 1
• Clindamycin is specifically indicated for serious skin and soft tissue infections caused by susceptible anaerobic bacteria, streptococci, and staphylococci 3

Alternative options (for penicillin allergy):

• Clindamycin plus ciprofloxacin is recommended for patients with penicillin allergy 1
• For infections involving the perineum, cefoxitin and ampicillin-sulbactam are also considered effective options 2

Special Considerations

• Beta-lactams have shown inferior efficacy and more adverse effects compared to other antimicrobials for skin infections 1
• Fluoroquinolones should be reserved for cases where other antibiotics cannot be used due to their potential for collateral damage 1
• For recurrent infections, consider a 5-day decolonization regimen with intranasal mupirocin and chlorhexidine washes 1

Duration of Therapy

• For most uncomplicated cases, 5-7 days of antibiotic therapy is sufficient following adequate drainage 1
• For more severe or complicated infections, treatment may need to be extended to 10-14 days based on clinical response 2

Common Pitfalls and Caveats

• Failure to properly drain the abscess is the most common reason for treatment failure, not antibiotic selection 1, 4
• Antibiotics alone without drainage are insufficient for treating pilonidal abscesses 4
• Recurrence rates can be high (up to 14% within 12 months) even with appropriate initial management 4
• Ensure proper wound care and hair removal from the affected area to prevent recurrence 5
• Culture-directed antibiotic therapy should be considered if initial empiric therapy fails 3

Remember that while antibiotics are important in the management of infected pilonidal cysts, they should be used as an adjunct to proper surgical drainage, which remains the cornerstone of treatment 1, 4.