Excision for Recurrent MRSA Abscesses
Yes, excision should be considered when recurrent abscesses are caused by underlying structural pathology such as pilonidal cysts, hidradenitis suppurativa, or retained foreign material—eradicating these local factors can be curative. 1
When to Search for Excisable Causes
A recurrent abscess at the same anatomical site should immediately trigger evaluation for local structural causes that require surgical excision rather than repeated drainage. 1 The IDSA guidelines specifically identify three conditions where excision is potentially curative:
- Pilonidal cysts - particularly in the sacrococcygeal region 1
- Hidradenitis suppurativa - chronic inflammatory condition of apocrine glands 1
- Retained foreign material - splinters, debris, or other foreign bodies perpetuating infection 1
The Critical Distinction
The question of "excision" applies only to underlying structural pathology, not to the infected tissue itself. For standard recurrent MRSA abscesses without these predisposing factors, the treatment remains incision and drainage—not excision of skin or soft tissue. 1
Management Algorithm for Recurrent Abscesses
Step 1: Immediate Drainage
Perform incision and drainage for each recurrent abscess, regardless of the number of prior episodes. 1 This is non-negotiable and remains the primary treatment. 2
Step 2: Culture Early
Obtain wound cultures early in the course of recurrent infections to identify the pathogen and guide antibiotic selection. 1, 3 This is particularly important given that 55-57% of drained abscesses grow MRSA. 4, 5
Step 3: Evaluate for Structural Causes
If abscesses recur at the same anatomical location, perform a thorough examination and consider imaging to identify pilonidal disease, hidradenitis, or foreign bodies. 1 These conditions require definitive surgical excision of the affected tissue for cure.
Step 4: Antibiotic Therapy
Treat with a 5-10 day course of an antibiotic active against the isolated pathogen. 1 For confirmed MRSA, use trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily). 1, 3 Patients with MRSA are more likely to experience treatment failure with only 3 days versus 10 days of antibiotics (10.1% rate difference, P=0.03). 5
Step 5: Consider Decolonization (Limited Evidence)
A 5-day decolonization regimen may be considered: twice-daily intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items. 1 However, the evidence for decolonization preventing recurrence is weak and inconsistent—one pediatric study found no reduction in recurrence rates despite decolonization. 6 Military personnel studies showed nasal mupirocin alone was ineffective. 1
Critical Pitfalls
- Do not perform excision of normal skin/soft tissue in standard recurrent abscesses without underlying structural pathology—this is not indicated and will not prevent recurrence. 1
- Do not assume antibiotics alone will prevent recurrence without addressing underlying causes or performing adequate drainage. 1, 2
- Do not overlook family/household contacts as a source of reinfection—one study found that treating household contacts in addition to the patient significantly reduced recurrences. 1
Special Consideration: Neutrophil Disorders
Adult patients should be evaluated for neutrophil dysfunction disorders only if recurrent abscesses began in early childhood, as this suggests an underlying immunodeficiency rather than colonization or environmental factors. 1