What is the best course of treatment for a patient with recurrent abscesses (collections of pus) or furuncles (boils) in the gluteal region over a post-surgical site?

Management of Recurrent Gluteal Abscesses/Furuncles Over Post-Surgical Site

For recurrent abscesses/furuncles in the gluteal region over a post-surgical site, you must first search for local anatomic causes (pilonidal cyst, hidradenitis suppurativa, or retained foreign material), perform incision and drainage with culture, treat with targeted antibiotics for 5-10 days, and implement a comprehensive decolonization strategy including intranasal mupirocin and chlorhexidine washes. 1

Immediate Evaluation and Management

Search for Underlying Causes

• A recurrent abscess at a previous surgical site mandates evaluation for local anatomic factors that perpetuate infection 1:
  • Pilonidal cyst (particularly relevant in gluteal region)
  • Hidradenitis suppurativa
  • Retained foreign material (suture material, mesh, or other surgical debris)
  • These local factors, if present, must be eradicated as they can be curative 1

Acute Lesion Management

• Perform incision and drainage for all large furuncles and abscesses (strong recommendation, high-quality evidence) 1, 2
• Culture the abscess early in the course of infection to identify the causative organism and guide antibiotic selection 1, 3
• After drainage, cover with a dry dressing rather than packing with gauze—packing adds unnecessary pain without improving outcomes 4, 3

Antibiotic Therapy

When to Use Antibiotics

For recurrent abscesses, antibiotics ARE indicated (unlike simple first-time abscesses) 1:

• Treat with a 5-10 day course of an antibiotic active against the pathogen isolated from culture 1
• Choose MRSA-active agents (trimethoprim-sulfamethoxazole, doxycycline, or clindamycin) given high community prevalence 4, 3, 2
• Also use antibiotics if SIRS is present (fever >38°C or <36°C, tachycardia >90 bpm, tachypnea >24/min, WBC >12,000 or <4,000) 1

Decolonization Strategy for Recurrent Disease

Implement a comprehensive 5-day decolonization regimen (this is critical for preventing future recurrences) 1:

The Three-Component Approach

1. Intranasal mupirocin 2% ointment twice daily for 5 days 1, 4, 3
2. Daily chlorhexidine body washes for 5-14 days 1, 4, 3
3. Daily decontamination of personal items (towels, sheets, clothing) 1, 4, 3

Important Caveats About Decolonization

• The evidence for decolonization efficacy in the MRSA era is mixed—older trials showed benefit, but more recent military studies showed intranasal mupirocin alone was ineffective 1
• However, the combination approach (mupirocin + chlorhexidine + environmental decontamination) appears more effective than single interventions 1
• Consider evaluating household members for S. aureus colonization if ongoing transmission is suspected 4, 3

Special Considerations for Post-Surgical Sites

Surgical Site-Specific Issues

• The gluteal region post-surgically is particularly prone to recurrence due to moisture, friction, and difficulty maintaining hygiene 5
• Retained foreign material from surgery (sutures, mesh) can serve as a nidus for persistent infection and must be actively sought 1
• Consider imaging (ultrasound or MRI) if physical examination doesn't reveal an obvious anatomic cause 1

When Decolonization Fails

• If recurrences continue despite optimal hygiene and decolonization, re-culture to ensure appropriate antibiotic coverage 3
• Some patients experience recurrences over years despite all measures, particularly with CA-MRSA clone ST80-IV 5
• Adult-onset recurrent abscesses do NOT require neutrophil function testing (only needed if abscesses began in early childhood) 1, 3

Preventive Hygiene Measures

Implement strict ongoing hygiene protocols 3:

• Cover all draining wounds
• Avoid sharing personal items
• Use separate towels and washcloths
• Clean surfaces that contact bare skin daily with commercial cleaners
• Apply these measures to all household members if transmission is suspected 3

Key Clinical Pitfall

The most common error is treating recurrent gluteal abscesses with drainage and antibiotics alone without searching for the underlying anatomic cause 1. In the gluteal region over a post-surgical site, pilonidal disease and retained foreign material are particularly important to exclude, as their eradication can be curative 1.