From the Guidelines
For recurrent gluteal abscesses after failed Bactrim treatment, I recommend prescribing clindamycin 300 mg orally four times daily for 10 days. This regimen provides good coverage against the likely causative organisms, particularly MRSA (methicillin-resistant Staphylococcus aureus), which commonly causes recurrent skin and soft tissue infections 1. The failure of Bactrim (trimethoprim-sulfamethoxazole) suggests either resistance to this antibiotic or the presence of anaerobic bacteria in the abscess, which clindamycin effectively targets. Clindamycin also has excellent tissue penetration and achieves high concentrations in abscesses.
Some key points to consider in the management of this patient include:
- The patient has already undergone incision and drainage (I&D) of the abscess, which is the primary treatment for cutaneous abscesses 1.
- The patient was initially treated with Bactrim, but the recurrence of abscesses suggests that this treatment was not effective, possibly due to resistance or the presence of anaerobic bacteria 1.
- Clindamycin is a suitable alternative for the treatment of MRSA infections, including skin and soft tissue infections, and has been recommended by the Infectious Diseases Society of America (IDSA) 1.
- The patient should be advised to complete the full 10-day course of antibiotics, even if symptoms improve earlier, to prevent further recurrence.
- Additionally, the patient should be advised to keep the wound clean and dry, use warm compresses to promote drainage, and return for follow-up if fever develops, the infection worsens, or new abscesses appear.
- If the patient has a history of inflammatory bowel disease or is at high risk for Clostridioides difficile infection, an alternative like doxycycline 100 mg twice daily for 10 days could be considered 1.
From the FDA Drug Label
Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Serious skin and soft tissue infections; septicemia; intra- abdominal infections such as peritonitis and intra-abdominal abscess Adults: Serious infections – 150 to 300 mg every 6 hours. More severe infections – 300 to 450 mg every 6 hours The patient has gluteal abscesses, which are considered serious skin and soft tissue infections. Based on the drug label, clindamycin is a suitable option for treatment.
- The recommended dose for adults with serious infections is 150 to 300 mg every 6 hours.
- The duration of treatment is not explicitly stated in the label, but it is generally recommended to continue treatment for at least 10 days in cases of β-hemolytic streptococcal infections.
- For other types of infections, the duration of treatment should be determined based on the clinical response of the patient 2 2.
From the Research
Antibiotic Recommendation
Based on the provided evidence, the patient's condition, and the fact that the patient has already been given 1g of ceftriaxone in the ED, the following antibiotic is recommended for outpatient treatment:
- Clindamycin, as it is an oral antibiotic that offers good bioavailability and tissue penetration, and is effective against MRSA infections 3
- Dosage: 300-450 mg every 6 hours
- Frequency: Every 6 hours
- Duration: The length of antibiotic treatment required depends upon the severity of infection and pre-existing co-morbidities, but typically ranges from 7-14 days 3
Considerations
- The patient's response to treatment should be monitored to ensure cure of infection whilst preventing excessive antibiotic use 3
- The development of gluteal abscesses as a complication of transgluteal drainage of pelvic abscesses is a possibility, as seen in the literature 4
- The patient's condition and medical history should be taken into account when determining the best course of treatment, including the use of antibiotics and the duration of treatment 5