Management of Infected Pilonidal Cysts

Initial Management

• Incision and drainage is the recommended primary treatment for inflamed pilonidal cysts and abscesses, with systemic antibiotics added based on the presence or absence of systemic inflammatory response syndrome (SIRS) such as fever, tachypnea, tachycardia, or abnormal white blood cell count 1

Antibiotic Selection

• For moderate to severe infections, the Infectious Diseases Society of America recommends clindamycin 300-450 mg orally three times daily plus trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily) as a first-line option 1
• For patients with penicillin allergy, clindamycin plus ciprofloxacin is a recommended alternative 3

Special Considerations

• The Infectious Diseases Society of America recommends treating recurrent pilonidal abscesses with antibiotics active against the isolated pathogen, and considering a 5-day decolonization regimen with intranasal mupirocin and chlorhexidine washes for patients with recurrent infections 1

Cautions

• Beta-lactams have inferior efficacy and more adverse effects compared to other antimicrobials for skin infections, according to the Infectious Diseases Society of America 5
• Fluoroquinolones should be reserved for cases where other antibiotics cannot be used due to their propensity for collateral damage, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 6