What is the treatment for carbuncles?

Treatment of Carbuncles

All carbuncles require incision and drainage as the primary treatment, with systemic antibiotics reserved for patients who have signs of systemic infection (fever, tachycardia, elevated white blood cell count) or extensive surrounding cellulitis. 1

Primary Treatment: Incision and Drainage

• Incision and drainage is mandatory for all carbuncles (strong recommendation, high-quality evidence) 1
• The procedure should include thorough evacuation of pus and probing the cavity to break up loculations 1
• After drainage, simply cover the surgical site with a dry sterile dressing—this is more effective than packing with gauze, which causes more pain without improving healing 1
• Obtain Gram stain and culture of the pus, though treatment without these studies is reasonable in typical cases 1

When to Add Systemic Antibiotics

Antibiotics are NOT routinely needed after drainage alone. The decision to add antibiotics should be based on specific clinical criteria 1:

Indications for Antibiotic Therapy:

• Presence of SIRS criteria: temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or WBC >12,000 or <4,000 cells/µL 1
• Extensive surrounding cellulitis 1
• Fever or other systemic manifestations 1
• Markedly impaired host defenses (diabetes, immunocompromised) 1
• Multiple lesions 1

Antibiotic Selection When Indicated

For Methicillin-Sensitive S. aureus (MSSA):

• Dicloxacillin 500 mg orally every 6 hours 2
• Take on an empty stomach (at least 1 hour before or 2 hours after meals) with at least 4 ounces of water 2
• Avoid taking in supine position or immediately before bed 2

For Suspected or Confirmed MRSA:

• Clindamycin 300-450 mg orally every 6 hours 3
• Take with a full glass of water to avoid esophageal irritation 3

Duration:

• 5-10 days for most cases 1
• Continue for at least 48 hours after the patient becomes afebrile and asymptomatic 2

Management of Recurrent Carbuncles

If a patient develops recurrent carbuncles, implement the following decolonization strategy 1:

• Intranasal mupirocin twice daily for 5 days each month 1
• Daily chlorhexidine body washes 1
• Daily decontamination of personal items (towels, sheets, clothing) 1
• Search for local causes such as pilonidal cysts or foreign material 1
• Culture recurrent abscesses early and treat with 5-10 days of pathogen-directed antibiotics 1

Special Populations

Diabetic Patients:

• Carbuncles commonly develop on the back of the neck in diabetics 1
• Have a lower threshold for initiating systemic antibiotics due to impaired host defenses 1
• Monitor more closely for complications 4

Immunocompromised Patients:

• Always use an antibiotic active against MRSA in addition to drainage 1
• Consider more aggressive treatment with closer monitoring 4

Common Pitfalls to Avoid

• Do NOT use ultrasonographically guided needle aspiration—it has only 25% success rate overall and <10% with MRSA infections 1
• Do NOT pack wounds with gauze routinely—this causes more pain without improving healing 1
• Do NOT prescribe antibiotics without drainage—incision and drainage is the cornerstone of treatment, and antibiotics alone are insufficient 1
• Do NOT assume all carbuncles need antibiotics—most can be managed with drainage alone unless systemic signs are present 1