What is the treatment for a female with recurrent furuncles (boils) on the buttocks, who has taken doxycycline, cephalexin (Keflex), and trimethoprim-sulfamethoxazole (Bactrim), with symptoms of nausea and recurring infections?

Treatment for Recurrent Furuncles (Boils) with Antibiotic Intolerance

For this patient with recurrent furuncles on the buttocks who has failed multiple antibiotic courses and is experiencing antibiotic-related nausea, the priority should shift to decolonization strategies combined with incision and drainage when needed, rather than continued systemic antibiotics. 1

Immediate Management Approach

Decolonization Protocol (First-Line Strategy)

• Implement a 5-day decolonization regimen that includes: 1
  • Intranasal mupirocin ointment applied twice daily
  • Daily chlorhexidine body washes
  • Daily decontamination of personal items (towels, sheets, clothing)
• This approach is specifically recommended for recurrent S. aureus infections and addresses the underlying colonization that drives recurrence 1
• This strategy avoids the gastrointestinal side effects that are problematic with oral antibiotics while targeting the root cause 1

Surgical Management

• Incision and drainage remains the cornerstone of treatment for any new boils that develop 1, 2
• Drainage alone achieves cure rates of 85-90% for simple abscesses without requiring systemic antibiotics 2
• Culture any drained material to guide future antibiotic selection if needed 1

When Antibiotics Are Necessary

Alternative Antibiotic Selection

If systemic antibiotics become necessary for a new boil with surrounding cellulitis or systemic symptoms:

• Clindamycin 300-450 mg orally four times daily is the preferred alternative 1

  • Provides coverage for both MRSA and streptococci 1, 2
  • May cause less nausea than the previously tried agents
  • Should only be used if local MRSA clindamycin resistance is <10% 2
  • Duration: 5-7 days 1

• Cephalexin 500 mg orally four times daily is an alternative if MRSA is not suspected 1, 3

  • First-generation cephalosporin with excellent coverage for typical pathogens 3
  • May be better tolerated than doxycycline or Bactrim in terms of GI side effects 3

Important Caveat on Antibiotic Duration

• Limit treatment to 5-7 days maximum to reduce adverse effects and antibiotic resistance 1, 4
• The evidence shows that prolonged antibiotic courses do not prevent recurrence once therapy stops 4
• Recurrence rates remain similar regardless of antibiotic choice, emphasizing that decolonization is more important than antibiotic selection 4

Addressing Antibiotic-Related Nausea

Risk Mitigation Strategies

• Take antibiotics with food to minimize gastrointestinal upset (general medical practice)
• Consider anti-nausea medication if antibiotics are absolutely required (general medical practice)
• Avoid trimethoprim-sulfamethoxazole given her prior intolerance and the risk of severe adverse reactions including eosinophilic gastroenteritis 5

Long-Term Prevention Strategy

Ongoing Decolonization

• Repeat the 5-day decolonization protocol monthly or at first sign of new lesion development 1
• This is more effective than chronic antibiotic suppression for preventing recurrence 1

Evaluation for Underlying Conditions

• Screen for diabetes mellitus if not already done, as this increases risk of recurrent skin infections 1
• Consider evaluation for neutrophil disorders if recurrences continue despite appropriate management 1
• Assess for household contacts who may be colonized carriers requiring decolonization 1

Critical Pitfalls to Avoid

• Do not prescribe chronic antibiotic prophylaxis for recurrent boils—this approach is not supported by evidence and increases resistance risk 1, 4
• Do not continue cycling through different oral antibiotics without implementing decolonization measures, as this perpetuates the cycle of recurrence and side effects 1, 4
• Do not assume MRSA coverage is always necessary—many recurrent boils are due to colonization rather than resistant organisms, making decolonization more important than antibiotic choice 1