Treatment of Furuncles in Skilled Nursing Facilities
For small furuncles in a skilled nursing home, apply moist heat several times daily to promote spontaneous drainage, then cover with a dry dressing once drainage occurs; larger furuncles require incision and drainage, with systemic antibiotics reserved only for patients with fever, extensive cellulitis, multiple lesions, or immunocompromising conditions. 1, 2
Initial Assessment and Size-Based Treatment Algorithm
Small Furuncles
- Apply warm, moist compresses several times daily to promote spontaneous drainage 1, 2
- Once drainage occurs, cover the area with a dry sterile dressing 1, 2
- This conservative approach achieves cure rates of 85-90% without antibiotics 2
Large Furuncles and All Carbuncles
- Perform incision and drainage as the cornerstone of treatment 1, 2
- Thoroughly evacuate pus and probe the cavity to break up any loculations 3
- Cover the surgical site with a dry dressing rather than packing with gauze, as packing causes unnecessary pain without improving outcomes 3, 2
- Obtain Gram stain and culture of the purulent material 3
When to Add Systemic Antibiotics
Antibiotics are NOT routinely needed after adequate drainage unless specific complications are present 1, 2. Add systemic antibiotics only when:
- Fever is present (temperature >38°C or <36°C) 1, 3, 2
- Extensive surrounding cellulitis extends beyond the furuncle 1, 2
- Multiple lesions are present 1, 3, 2
- Immunocompromising conditions exist (common in skilled nursing facilities due to advanced age, diabetes, or other comorbidities) 3, 2
- Signs of systemic inflammatory response including tachycardia >90 bpm, tachypnea >24 breaths/min, or abnormal white blood cell count 3
Antibiotic Selection When Indicated
Choose agents active against Staphylococcus aureus with consideration for MRSA coverage given high community prevalence 2:
- Trimethoprim-sulfamethoxazole 2
- Doxycycline 2
- Clindamycin 2
- Cephalexin or dicloxacillin (if MSSA suspected and MRSA prevalence is low) 2
Adjust therapy based on culture and susceptibility results when available 3, 2.
Critical Considerations for Skilled Nursing Facilities
Infection Control Measures
Skilled nursing facilities require heightened infection control due to close living quarters and potential for outbreaks 1:
- Implement bathing with chlorhexidine antibacterial soap 1
- Ensure thorough laundering of clothing, towels, and bed linens 1
- Mandate separate use of towels and washcloths 1
- Screen and treat colonized residents to eradicate staphylococcal carriage 1
Recurrent Furunculosis Management
If a resident experiences repeated episodes, implement a comprehensive decolonization strategy 2:
- Intranasal mupirocin 2% ointment applied twice daily in the anterior nares for the first 5 days each month (reduces recurrences by ~50%) 1, 2
- Daily chlorhexidine body washes 2
- Daily decontamination of personal items 2
- Consider oral clindamycin 150 mg daily for 3 months for recurrent cases caused by susceptible S. aureus (decreases subsequent infections by ~80%) 1, 4
- Culture recurrent lesions early to identify the causative organism 2
- Evaluate household contacts and other residents for S. aureus colonization 2
Common Pitfalls to Avoid
- Do not routinely prescribe antibiotics for simple furuncles after adequate drainage - this contributes to antibiotic resistance without improving outcomes 1, 2
- Do not pack wounds with gauze - this increases pain without benefit 3, 2
- Do not overlook the need for facility-wide infection control measures when outbreaks occur, as inadequate hygiene and close contact facilitate transmission 1
- Do not assume MSSA in skilled nursing facilities - consider MRSA coverage empirically given the high-risk population and institutional setting 2