Management of Infected Pilonidal Abscess

Initial Therapeutic Approach

The American College of Surgeons recommends incision and drainage as the primary treatment for acute infected pilonidal abscess, followed by elective excision with primary closure after resolution of acute inflammation (8-14 days) 1, 2
The Infectious Diseases Society of America suggests that antibiotics are recommended as adjunctive treatment in situations such as presence of systemic signs of infection, extensive cellulite around the abscess, or immunocompromised patients 1, 2
The strength of evidence for the use of antibiotics in these situations is moderate, with a recommendation grade of B 1

The Clinical Infectious Diseases guidelines recommend that the empirical antibiotic regimen should cover both aerobic and anaerobic pathogens (e.g., cephalexin + metronidazole for 7 days) 1
For simple abscesses without systemic signs in immunocompetent patients, antibiotics are not necessary after adequate drainage 1, 2

The Clinical Infectious Diseases guidelines suggest that after initial drainage and resolution of acute inflammation (8-14 days), an elective excision of the pilonidal sinus should be planned 1, 2
The recommended median delay is 9 weeks after initial drainage 1

The excision with Limberg flap is the recommended technique for primary closure after sinus excision, with a recurrence rate of only 2.6% and a low complication rate (10.4%) 1, 2

The Praxis Medical Insights guidelines recommend avoiding immediate primary closure during acute abscess drainage, as it is associated with a higher recurrence rate (14%) compared to secondary healing 2
The Clinical Infectious Diseases guidelines suggest that curettage of the abscess cavity is superior to simple drainage, with a healing rate of 96% versus 78.7% for drainage alone 1