What antibiotic is recommended for a pilonidal (pilonidal) cyst?

Antibiotic Treatment for Pilonidal Cysts

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

Primary Management Approach

• Incision and drainage is the cornerstone of treatment for inflamed pilonidal cysts and abscesses, with antibiotics serving as an adjunctive therapy 1
• Antibiotics should be added based on the presence of systemic inflammatory response syndrome (SIRS) such as fever, tachycardia, tachypnea, or abnormal white blood cell count 2
• Failure to properly drain the abscess is the most common reason for treatment failure, not antibiotic selection 1

Recommended Antibiotic Regimens

First-line therapy:

• Clindamycin 300-450 mg orally three times daily plus trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily) 1, 2

For patients with penicillin allergy:

• Clindamycin plus ciprofloxacin 1, 2

Alternative options for perineal infections:

• Cefoxitin or ampicillin-sulbactam 1

Duration of Antibiotic Therapy

• For most uncomplicated cases: 5-7 days following adequate drainage 1
• For more severe or complicated infections: 10-14 days based on clinical response 1

Special Considerations

• Beta-lactams have shown inferior efficacy and more adverse effects compared to other antimicrobials for skin infections 1, 2
• Fluoroquinolones should be reserved for cases where other antibiotics cannot be used due to their potential for collateral damage 1, 2
• For recurrent infections, consider a 5-day decolonization regimen with intranasal mupirocin and chlorhexidine washes 1, 2

Treatment Algorithm

1. Perform incision and drainage of the pilonidal cyst 1
2. Assess for signs of systemic infection (SIRS) 2
3. If systemic infection is present, initiate antibiotic therapy with clindamycin plus trimethoprim-sulfamethoxazole 1, 2
4. For penicillin-allergic patients, use clindamycin plus ciprofloxacin 1, 2
5. Continue antibiotics for 5-7 days in uncomplicated cases, extending to 10-14 days for severe infections 1
6. Monitor for clinical improvement within 72 hours 1
7. For recurrent infections, add decolonization protocol with mupirocin and chlorhexidine 1, 2

Common Pitfalls to Avoid

• Relying solely on antibiotics without adequate surgical drainage 1
• Using beta-lactams as first-line therapy due to their inferior efficacy in skin infections 1, 2
• Overuse of fluoroquinolones when other options are available 1, 2
• Inadequate duration of therapy leading to treatment failure 1
• Failure to consider recurrent infection management strategies 1, 2