Management of Carbuncles
Carbuncles require incision and drainage as the primary treatment, with systemic antibiotics reserved for patients with systemic signs of infection, extensive surrounding cellulitis, multiple lesions, or immunocompromised status. 1
Primary Treatment: Incision and Drainage
Perform incision and drainage for all large carbuncles as the cornerstone of therapy, with thorough evacuation of pus and probing of the cavity to break up loculations. 1, 2
After drainage, cover the wound with a dry sterile dressing rather than packing with gauze—packing is unnecessary, adds pain without improving outcomes, and does not enhance healing. 1, 2
Obtain Gram stain and culture of pus from the carbuncle to identify the causative organism and guide antibiotic selection if needed. 1, 2
When to Add Systemic Antibiotics
Antibiotics are NOT routinely needed for carbuncles after adequate drainage alone. 1 However, systemic antibiotics active against Staphylococcus aureus should be prescribed when ANY of the following conditions exist:
Fever or systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachycardia >90 beats/min, tachypnea >24 breaths/min, or abnormal white blood cell count 1, 2
Extensive surrounding cellulitis extending beyond the borders of the carbuncle 1, 2
Markedly impaired host defenses: immunocompromised patients, diabetes, or infants (who are considered hosts with potentially impaired defenses) 1, 2
Antibiotic Selection
Use MRSA-active antibiotics empirically given the high prevalence of methicillin-resistant S. aureus in community-acquired skin infections. 1, 3
Preferred oral agents for MRSA coverage: trimethoprim-sulfamethoxazole (Bactrim), doxycycline, or clindamycin 1, 2
For hospitalized patients requiring IV therapy: vancomycin is the standard choice for confirmed or suspected MRSA infection 3
First-generation cephalosporins (e.g., cephalexin) can be used if methicillin-sensitive S. aureus (MSSA) is suspected or confirmed 2
Adjust therapy based on culture and susceptibility results when available 2
Management of Recurrent Carbuncles
Culture recurrent lesions early to identify the causative organism and guide antibiotic selection. 1
Search for local anatomic causes: pilonidal cyst, hidradenitis suppurativa, or retained foreign material that may predispose to recurrence. 1
Offer decolonization when: patient experiences recurrent skin infections despite optimizing wound care and hygiene measures, or ongoing transmission occurs among household members or close contacts. 1
Decolonization Regimen
Intranasal mupirocin 2% ointment twice daily for 5 days 1
Daily decontamination of personal items (towels, washcloths, clothing) 1
Environmental hygiene measures: cover all draining wounds, avoid sharing personal items, use separate towels and washcloths, and clean surfaces that contact bare skin daily with commercial cleaners 1
Important Clinical Caveats
Screening cultures before decolonization are NOT routinely recommended if at least one prior infection was documented as MRSA. 1
Surveillance cultures after decolonization are NOT routinely recommended in the absence of active infection. 1
Nasal colonization with S. aureus is the primary identifiable predisposing factor for most individuals with recurrent disease. 1
For infants with recurrent carbuncles beginning in early childhood, evaluate for neutrophil disorders or underlying immune deficiency—this is NOT needed for adult-onset disease. 1, 2
When household transmission is suspected, evaluate all contacts for evidence of S. aureus infection and apply hygiene measures to all household members. 1
Close follow-up is essential to ensure resolution of infection; if lesions are not improving with initial therapy, consider inadequate drainage, resistant organisms, or underlying conditions predisposing to infection. 2