What is the recommended treatment for a recurrent vulvar abscess, given a history of similar abscesses responsive to Augmentin (amoxicillin/clavulanate)?

Management of Recurrent Vulvar Abscess

For a recurrent vulvar abscess with a history of response to Augmentin, the recommended treatment is incision and drainage as the primary intervention, followed by a 5-10 day course of Augmentin (amoxicillin-clavulanate) to prevent recurrence.

Primary Management

• Incision and drainage is the primary treatment for vulvar abscesses, as it is for all skin and soft tissue abscesses 1
• For recurrent abscesses specifically, early drainage and culture are strongly recommended to guide targeted antibiotic therapy 1
• After drainage, the abscess cavity should be thoroughly explored to identify any potential underlying causes such as foreign material or communication with deeper tissues 1

Antibiotic Therapy

• For recurrent abscesses, a 5-10 day course of antibiotics active against the isolated pathogen is recommended following drainage 1
• Since the patient has previously responded well to Augmentin (amoxicillin-clavulanate), this is an appropriate choice for empiric therapy given its broad spectrum coverage against common skin and soft tissue pathogens 2
• Augmentin provides coverage against both aerobic and anaerobic bacteria commonly found in vulvar abscesses, including Staphylococcus aureus and various anaerobes 3, 4

Special Considerations for Recurrent Vulvar Abscesses

• A thorough examination should be performed to rule out underlying conditions such as hidradenitis suppurativa, which can cause recurrent abscesses in the vulvar region 1
• Culture of the abscess material is particularly important in recurrent cases to identify potential resistant organisms and guide future therapy 1
• If MRSA is suspected based on local prevalence or previous cultures, alternative antibiotics such as trimethoprim-sulfamethoxazole, clindamycin, or doxycycline should be considered 1

Prevention of Recurrence

• Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items (towels, sheets, clothes) if S. aureus is identified as the causative organism 1
• Regular follow-up is recommended to monitor for complete resolution and early signs of recurrence 1
• Patients with multiple recurrences despite appropriate treatment should be evaluated for underlying immunological disorders, especially if recurrences began in early childhood 1

When to Consider Hospitalization

• Hospitalization and parenteral antibiotics should be considered if any of the following are present:
  • Systemic inflammatory response syndrome (SIRS) (temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or abnormal white blood cell count) 1
  • Extensive surrounding cellulitis or rapid progression of infection 1
  • Immunocompromised status 1
  • Failed outpatient management 1

Potential Complications and Pitfalls

• Inadequate drainage is a common cause of treatment failure and recurrence; ensure complete evacuation of the abscess cavity 1
• Avoid probing for fistulas during the drainage procedure as this may create iatrogenic complications 1
• Be aware that vulvar abscesses may communicate with deeper tissues, requiring more extensive surgical exploration in some cases 1
• Recurrent vulvar abscesses may indicate an underlying condition requiring specialized evaluation 1

By following this approach of prompt surgical drainage combined with appropriate antibiotic therapy with Augmentin, most patients with recurrent vulvar abscesses can achieve complete resolution and reduced risk of future recurrences.