Antibiotics and Cutaneous Abscesses – Is there a Role?
Search Strategy: Realizing that most of the literature on abscesses may be dated you opt for OVID from 1966 to present. Your initial search for “cutaneous abscess” turns up 45 results which you quickly review. While this initial search yielded a conveniently small number, you realize that you are likely overlooking some useful articles with such a narrow search. Saving this result you again search under “skin abscess” and apply the OVID-filters of Human studies and English with 34 citations identified. Unfortunately, the two search strategies only produce one 1985 article which appears useful in answering your PICO question by Llera. You review the bibliography of Llera’s paper and identify two other promising older articles. Finally, you consult your Surgical and Infectious Disease colleagues for their knowledge of this common clinical question and are provided with a more timely pediatric review from 2004 in the era of MRSA.
While working a busy night in the “Deuce” carrying three-quarters of the patients as your attending kicks back to check the latest on their fantasy football team, you see another new hall patient on the board and eagerly dive into yet another learning opportunity. The nursing note on the computer reads as follows.
- HPI: Chief Complaint: A 23 year old male with a “spider bite” on his left “ass cheek” which he noted 3-days ago. The lesion has become progressively larger and more painful with drainage of yellow-white fluid in the shower today prompting his presentation to the ED. Patient is eating, laughing, and joking with friends and not in distress to this RN. He has no stated Past Medical or Past Surgical History. He denies any daily prescription or over-the-counter medication use or illicit substance abuse.
- Vital signs: Temp 37.0C, HR 90, BP 145/76, Resp 26, 99% on room air
Physical exam is unimpressive other than a tender, swollen, pointed abscess on the lateral portion of his left buttock measuring 4 cm in diameter with a small amount of purulent drainage from the pointed area. While there is no overlying cellulitis, a small (<1 cm) ring of inflammation circumferentially surrounds the abscess.
Disappointed that the abscess is neither large nor complicated enough to require operative intervention, you resign yourself to an immediate incision and drainage (I&D). You’ve done innumerable I&D’s without a second thought, but with your first moonlighting gig less than a week away you ask yourself, “Self, what is the best evidence for properly treating an abscess?” While usually opinionated and boisterous, “Self” is quiet tonight. You decide to tackle this problem online.
Population: Immunocompetent ED patients presenting cutaneous abscess
Intervention: Incision & Drainage with antibiotics
Comparison: Incision & Drainage without antibiotics
Outcome: Recurrent same-site abscesses, repeat incision & drainage incidence, duration of symptoms, post-drainage ED recidivism, post-drainage hospitalization, sepsis-related 1-month mortality.
First years: Antibiotics in Surgical Treatment of Septic Lesions, Lancet 1970; 1: 1077-1080.
Second years: The Treatment of Acute Superficial Abscesses: A Prospective Clinical Trial. Brit J Surg 1977; 64: 264-266.
Third years: Treatment of Cutaneous Abscess: A Double-Blind Clinical Study. Annals EM 1985; 14: 15-19.
Fourth years: Management and Outcome of Children with Skin and Soft Tissue Abscesses Caused by Community-Acquired Methicillin-resistent Staphylococcus aureus. Pediatr Infect Dis 2004; 23: 123-127.
Article 1: Antibiotics in Surgical Treatment of Septic Lesions, Lancet 1970; 1: 1077-1080
Article 2: The treatment of acute superficial abscesses: a prospective clinical trial. Brit J Surgery 1977; 64: 264-266
Article 3: Treatment of Cutaneous Abscess: A Double-Blind Clinical Study, Annals EM 1985; 14: 15-19
Article 4: Management & Outcome of Children with Skin & Soft Tissue Abscesses Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Ped ID J 2004; 23: 123-127
After discussions with Infectious Disease, Pediatrics, and Surgery these are the conclusions.
- The literature is sparse, dated, and of overall poor quality. Appropriately powered, randomized controlled trials are needed in the era of community acquired methicillin resistant Staph aureus (ca-MRSA) to assess the effect appropriate antimicrobial coverage has on abscess healing rates, recurrence, pain and cosmesis scores, and evolving community antimicrobial resistance patterns.
- Until such studies are available, Surgery recommends routine abscess wound cultures and anti-MRSA antimicrobial coverage with Bactrim first-line therapy, Clindamycin second-line therapy. Some of the surgeons reported anecdotal success with quinolones at other institutions. The available literature (see critical appraisal forms below) does not support the general use of antibiotics before or after incision and drainage, although some studies note a trend towards diminished abscess recurrence. Note that the appropriate dose of Bactrim for abscess management is two tablets TID (not the one tablet BID dose we use for UTI!), which is particularly important in obese patients.
- For children, the general guidelines for a surgery consult (very physician specific) include wound location (groin, axilla, and pilonidal) and size (>5 cm). For adults, our surgeons advocate size >5cm as a chief indication for a surgery consult with 48-hour follow-up key to wound management. Of course, incision and drainage is first and foremost, the treatment-of-choice and procedural sedation plays an indispensable role in effective eradication of loculations and abscess packing.
- Other general guidelines for when to consider antibiotics which have been suggested (ACEP News September 2006 p 15) include: