Antibiotic therapy for vulvar abscess

Antibiotic(s)	Dosing (adult patients with normal organ function)
Empiric oral antibiotic therapy options for vulvar abscess* (treatment is recommended for 5 to 7 days)
Preferred: Trimethoprim-sulfamethoxazole (co-trimoxazole)^¶ or Trimethoprim-sulfamethoxazole^¶ plus amoxicillin-clavulanate or Trimethoprim-sulfamethoxazole^¶ plus metronidazole	Trimethoprim-sulfamethoxazole (co-trimoxazole): 1 to 2 DS tablets orally twice daily Amoxicillin-clavulanate: 875 mg orally twice daily Metronidazole: 500 mg orally 3 times daily Doxycycline: 100 mg orally twice daily Minocycline: 200 mg orally once, then 100 mg orally twice daily Clindamycin: 450 mg orally 3 times daily Ciprofloxacin: 500 mg orally twice daily
Alternatives: Doxycycline plus amoxicillin-clavulanate or Doxycycline plus metronidazole or Minocycline plus amoxicillin-clavulanate or Minocycline plus metronidazole
Less-preferred alternatives (according to local resistance patterns): Clindamycin^Δ plus amoxicillin-clavulanate or Clindamycin^Δ plus ciprofloxacin
Empiric intravenous antibiotic therapy options for severe vulvar abscess^◊
One of the following: Vancomycin Daptomycin Teicoplanin^§ (where available) PLUS one of the following: Ampicillin-sulbactam Piperacillin-tazobactam^¥ Ceftriaxone plus metronidazole Ciprofloxacin plus metronidazole Levofloxacin plus metronidazole	Vancomycin:^‡ Loading dose (optional): 20 to 35 mg/kg IV once Initial maintenance dose and interval: Typically 15 to 20 mg/kg IV every 8 to 12 hours or determined by use of a locally validated initial dosing nomogram Subsequent dose and interval adjustments: Generally based on AUC-guided or trough-guided serum concentration monitoring Daptomycin: 4 to 6 mg/kg IV every 24 hours Teicoplanin^§ (not available in the United States and Canada): Loading dose: 6 mg/kg IV every 12 hours for 3 doses Maintenance dose: 6 mg/kg IV or IM once daily to achieve target trough concentration >10 mg/L Ampicillin-sulbactam: 3 g IV every 6 hours Piperacillin-tazobactam: 3.375 g IV every 6 hours or 4.5 g IV every 8 hours Ceftriaxone: 1 to 2 g IV every 24 hours Metronidazole: 500 mg IV every 8 hours Ciprofloxacin: 400 mg IV every 12 hours Levofloxacin: 750 mg IV every 24 hours

DS: double-strength (ie, trimethoprim 160 mg with sulfamethoxazole 800 mg per tablet); IV: intravenously; AUC: area under the plot of plasma concentration of a drug versus time; IM: intramuscularly; MRSA: methicillin-resistant Staphylococcus aureus.
* Not all vulvar abscesses require antibiotic therapy; indications for empiric oral antibiotic therapy are discussed in the vulvar abscess topic within UpToDate.
¶ Due to increasing rates of Escherichia coli resistance to trimethoprim-sulfamethoxazole (co-trimoxazole), local resistance patterns must be considered before using this antibiotic as empiric treatment.
Δ Clindamycin has a higher risk of Clostridioides (formerly Clostridium) difficile infection and a higher rate of nonsusceptibility to MRSA; other regimens are generally preferred. Refer to the topics on treatment of MRSA for additional information.
◊ IV therapy is warranted if any one of the following features are present: severe infection (eg, fever >100.4°F [38°C] and chills with sustained tachycardia), rapid progression of erythema, proximity to an indwelling medical device such as a vascular graft, necrotizing fasciitis, or inability to tolerate oral medications. In general, in patients receiving IV therapy, discrete abscesses should be drained and specimens sent for culture and susceptibility testing. IV therapy can be switched to an oral regimen, preferably tailored to the culture and susceptibility results, after signs of infection begin to resolve. Total duration of therapy is typically 7 to 10 days.
§ In areas outside of the United States and Canada where teicoplanin is available, some use it as the drug of choice for initial therapy of gram-positive pathogens, while others favor its use for patients with intolerance to vancomycin.
¥ Risk of nephrotoxicity is increased when piperacillin-tazobactam is given in combination with vancomycin.
‡ For severely ill patients, a vancomycin loading dose may be considered. Refer to the UpToDate clinical topic review of vancomycin dosing for guidance on individualizing the loading dose, sample dosing nomogram, and serum concentration monitoring.

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Antibiotic therapy for vulvar abscess