SIGNS AND SYMPTOMS 
- Local:
- Systemic:
- Often absent
- Patients with extensive soft tissue involvement, necrotizing fasciitis, or underlying bacteremia may present with signs of sepsis including:
History
- Previous episodes: Raise concern for CA-MRSA
- Immunosuppression
- Medications:
- Chronic steroids, chemotherapy
- IVDU
- History of mammalian bite
Physical Exam
- Location and extent of infection
- Presence of:
- Associated cellulitis
- Subcutaneous air
- Deep structure involvement
- Involvement of specialty area:
ESSENTIAL WORKUP
- History and physical exam
- Gram stain unnecessary for simple abscesses in healthy patients
- Wound cultures:
- Not indicated in simple abscesses
- May help guide therapy if systemic treatment is planned
- May be useful in confirming CA-MRSA in patients with recurrent abscesses
- May guide specific therapy in a compromised host, abscesses of the central face or hand, and treatment failures
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Routine laboratory tests are not typically indicated.
- Glucose determination may be useful if:
- Underlying undiagnosed diabetes is a concern
- There is a concern for associated DKA
- For febrile patients who appear septic, systemically ill, or have recent IVDU the following labs are indicated:
- Blood cultures
- Lactate
- Renal function
- CK if myositis suspected
Imaging
- Bedside US can be helpful in distinguishing cellulitis from abscess
- CT/MRI can be helpful in determining deep tissue involvement
- Plain films may reveal gas in tissue planes
DIFFERENTIAL DIAGNOSIS
- Cellulitis
- Necrotizing fasciitis
- Aneurysm (especially with IV drug abusers)
- Cysts
- Hematoma
[Outline]
PRE-HOSPITAL
Caution: Septic patients may require rapid transport with IV access and volume resuscitation.
INITIAL STABILIZATION/THERAPY
Septic patient:
- Immediate IV access
- Oxygen
- Crystalloid volume resuscitation
- Blood cultures/lactate
- Early antibiotic therapy—broad spectrum to include MRSA coverage.
- Rapid source control (abscess drainage)
- If patient remains hypotensive after volume resuscitation consider:
- Central venous pressure monitoring
- Mixed venous sampling
ED TREATMENT/PROCEDURES
- Incision and drainage are the mainstays of treatment.
- Incision should be deep enough to allow adequate drainage
- Elliptical incision prevent early closure
- Break loculations with gentle exploration
- Irrigate cavity after expressing all pus
- Loose packing of abscess cavity when:
- Larger than 5 cm
- Comorbid medical conditions
- HIV
- Diabetes
- Malignancy
- Chronic steroid use
- Immunosuppressed
- Abscess location: face, neck, scalp, hands/feet, perianal, perirectal, genital
- Promote drainage and prevent premature closure
- For simple cutaneous abscesses (< 5 cm) packing may not be routinely indicated.
- Routine antibiotics are not indicated.
- Antibiotics are indicated for the following conditions:
- Sepsis/systemic illness
- Facial abscesses drained into the cavernous sinus
- Concurrent cellulitis (see "Medication")
- Mammalian bites
- Immunocompromised hosts
- Perirectal abscess requires treatment in the operating room
- Hand infections that may require surgical intervention:
- Deep abscesses
- Fight bite abscesses
- Associated tenosynovitis/deep fascial plane infection
- Loop drainage technique:
- Less invasive
- Simplifies wound care
- Procedure:
- Anesthetize locally
- Incision made at outer margin of abscess
- Use a hemostat to break loculations and manually express pus
- Use hemostat to localize distal margin of abscess and use as guide for a second incision
- Grasp silicone vessel loop with hemostat and pull through and then gently tie
- Patient should move loop daily to promote drainage
- No repeat ED visits generally required
- Removal in 7–10 days is painless
Pediatric Considerations
Incision and drainage are painful procedures that often require procedural sedation and analgesia.
MEDICATION
ALERT
- Know your local susceptibility patterns
- Oral antibiotics (moderate associated cellulitis):
- Amoxicillin/clavulanate:
- Use: Mammalian bites/MSSA/Streptococcus species
- Adult dose: 500–875 mg (peds: 40–80 mg/kg/d div q12h) PO q12h
- TMP-SMX:
- Use: MRSA
- Adult dose: 160/800 mg (peds: 4–5 mg/kg) PO BID
- Clindamycin:
- Use: MRSA
- Adult dose: 300–450 mg (peds: 4–8 mg/kg) PO q6h
- Doxycycline:
- Use: MRSA
- Adult dose: 100 mg (peds: over 8 yr: 1.1 mg/kg) PO q12h
- Cephalexin:
- Use: MSSA/Strep species
- Adult dose: 250 mg PO q6h or 500 mg PO q12h (peds: 25–50 mg/kg/d div q12h)
- Erythromycin:
- Use: MSSA/Streptococcus species
- Adult dose: 250–500 mg (peds: 10 mg/kg) PO q6–8h
- IV antibiotics (systemic illness or extensive associated cellulitis):
- Ampicillin/sulbactam
- Uses: Human/mammalian bites and facial cellulitis
- Adult dose: 1.5–3 g (peds: < 40 kg, 75 mg/kg; ≥40 kg, adult dose) IV q6h (max = 12 g/d)
- Vancomycin:
- Use: MRSA
- Adult dose: 15 mg/kg IV q12h (peds: 10–15 mg/kg/d div q6–8 h) (max. = 2,000 mg/d)
- Daptomycin:
- Use MRSA
- Adult dose: 4 mg/kg IV q24h
- Linezolid:
- Use: MRSA
- Adult dose: 600 mg IV/PO q12h (peds: 30 mg/kg/d div q8h)
- Clindamycin:
- Use: MRSA
- Adult dose: 600 mg (peds: 10–15 mg/kg) IV q8h
[Outline]
DISPOSITION
In accordance with abscess type and severity of infection
Admission Criteria
- Sepsis/systemic illness
- Immunocompromised host with moderate/large cellulitis
- Perirectal involvement
- Any abscess requiring incision and debridement in the operating room
Discharge Criteria
Most patients with uncomplicated abscesses can be treated with incision and drainage and close follow-up.
FOLLOW-UP RECOMMENDATIONS
- Recheck in 24–48 hr for packing removal and wound check.
- Warm soaks for 2–3 days after packing removal
[Outline]
- Alison DC, Miller T, Holtom P, et al. Microbiology of upper extremity soft tissue abscesses in injecting drug abusers. Clin Orth Related Res. 2007;461:9–13.
- Buescher ES. Community-acquired methicillin-resistant Staphylococcus aureus in pediatrics. Curr Opin Pediatr. 2005;17:67–70.
- Hankin A, Everett W. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med. 2007;50:49–51.
- Ladd AP, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2012:45:1562–1566.
- O'Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009;16:470–473.
- Tayal V, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. J Acad Emer Med. 2006;13:384–388.
- Tsoraides SS, Pearl RH, Stanfill AB, et al. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2012;45:606–609.
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