Treatment of Boils (Furuncles) with Antibiotics
Incision and drainage is the primary and most important treatment for boils, and antibiotics are typically unnecessary unless specific high-risk features are present. 1
Primary Treatment Approach
Incision and drainage alone is the recommended treatment for most boils without adjunctive antibiotics. 1 The decision to add antibiotics should be based on specific clinical criteria rather than routine use. 1
When to Add Antibiotics to Incision and Drainage
Add antibiotics directed against S. aureus when any of the following are present: 1
Systemic inflammatory response syndrome (SIRS) - defined as:
- Temperature >38°C or <36°C
- Tachypnea >24 breaths per minute
- Tachycardia >90 beats per minute
- White blood cell count >12,000 or <4,000 cells/µL 1
Severe or extensive disease involving multiple sites of infection 1
Rapid progression with associated cellulitis 1
Markedly impaired host defenses (immunosuppression) 1
Extremes of age 1
Difficult to drain locations (face, hand, genitalia) 1
Associated septic phlebitis 1
Lack of response to incision and drainage alone 1
Antibiotic Selection
For Community-Acquired MRSA Coverage (Outpatient)
When antibiotics are indicated, empirical coverage for CA-MRSA is recommended pending culture results: 1
- Clindamycin (first-line option) 1
- Trimethoprim-sulfamethoxazole (TMP-SMX) 1
- Tetracyclines (doxycycline or minocycline) 1
- Linezolid 1
Duration of Antibiotic Therapy
5 to 10 days of antibiotic therapy is recommended when antibiotics are used, based on clinical response. 1
Culture and Sensitivity Testing
- Gram stain and culture of pus from carbuncles and abscesses are recommended but treatment without these studies is reasonable in typical cases. 1
- Culture recurrent abscesses early in the course of infection. 1
Management of Recurrent Boils
For patients with recurrent S. aureus boils: 1
Consider a 5-day decolonization regimen including:
- Intranasal mupirocin twice daily
- Daily chlorhexidine washes
- Daily decontamination of personal items (towels, sheets, clothes) 1
Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material at sites of recurrent infection. 1
Treat with a 5- to 10-day course of an antibiotic active against the isolated pathogen. 1
Critical Pitfalls to Avoid
Do not use rifampin as a single agent or adjunctive therapy for treatment of skin and soft tissue infections including boils. 1
Avoid ultrasonographically guided needle aspiration as it was successful in only 25% of cases overall and <10% with MRSA infections. 1
Do not routinely prescribe antibiotics without incision and drainage - antibiotics without drainage are ineffective as the primary treatment modality. 1, 2
Recognize that most boils are caused by S. aureus (though this accounts for less than half of all cutaneous abscesses overall), and anaerobic bacteria are common in perineal locations. 2