Recurrent Abscess Management
For recurrent abscesses, drain and culture the lesion early, treat with a 5-10 day course of antibiotics targeting the isolated pathogen (typically anti-MRSA coverage), and implement a 5-day decolonization protocol with intranasal mupirocin twice daily, daily chlorhexidine washes, and decontamination of personal items. 1, 2
Initial Diagnostic Approach
Search for underlying anatomic causes before treating as simple recurrence:
- Evaluate for pilonidal cyst, hidradenitis suppurativa, or retained foreign material at the site 1, 2
- For breast location: consider involvement of lactiferous ducts requiring definitive surgical excision 3
- For perianal/gluteal location: assess for fistula formation or complex abscess cavities 2, 4
Acute Management
Incision and drainage remains the cornerstone of treatment:
- Drain the abscess promptly and obtain cultures early in the infection course 1, 2
- Culture results guide antibiotic selection rather than empiric prolonged therapy 1, 2
- Do not rely on drainage alone for recurrent cases—antibiotics are indicated 1, 2
Antibiotic Selection and Duration
Treat with pathogen-directed antibiotics for 5-10 days:
- For Staphylococcus aureus (most common): use trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for MRSA coverage 1, 2
- For severe infections with systemic signs: consider vancomycin, linezolid, or daptomycin 1, 2
- Extend therapy beyond 5 days only if clinical improvement is inadequate 1
Common pitfall: Inadequate antibiotic coverage significantly increases recurrence risk—one study showed a six-fold increase in readmission rates with inappropriate antibiotics 5. This underscores the importance of obtaining cultures rather than using empiric therapy alone.
Decolonization Protocol
After treating the acute infection, implement a 5-day decolonization regimen:
- Intranasal mupirocin twice daily 1, 2
- Daily chlorhexidine body washes 1, 2
- Daily decontamination of towels, sheets, and clothing 1, 2
This recommendation carries weak evidence quality but has low risk and potential benefit for preventing S. aureus recurrence 2.
Site-Specific Considerations
Breast abscesses require definitive surgical management:
- Simple incision and drainage results in nearly 100% recurrence rates 3
- Definitive surgical excision of the abscess cavity and involved lactiferous duct is necessary 3
- Use broad-spectrum antibiotics covering S. aureus and oral flora perioperatively (clindamycin or cephalosporin plus metronidazole) 3
Pilonidal abscesses:
- Systemic antibiotics are generally unnecessary after adequate drainage unless systemic signs, significant cellulitis, or immunocompromise are present 4
- Consider underlying pilonidal disease as the cause of recurrence 1, 2
Special Populations Requiring Antibiotics
Always use antibiotics in addition to drainage for:
- Surrounding cellulitis or erythema >2 cm 2
- Immunocompromised patients 2
- Systemic inflammatory response syndrome (SIRS) signs 1, 2
- Markedly impaired host defenses 1, 4
Evaluation for Underlying Disorders
Assess for neutrophil disorders only in specific circumstances: