Signs and Symptoms
- Local:
- Erythema
- Tenderness
- Heat
- Swelling
- Fluctuance
- May have surrounding cellulitis
- Regional lymphadenopathy and lymphangitis may occur
- Systemic:
- Often absent
- Patients with extensive soft tissue involvement, necrotizing fasciitis, or underlying bacteremia may present with signs of sepsis including:
- Fever
- Rigors
- Hypotension
- Altered mentation
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
Diagnostic Tests & Interpretation
Lab
- Routine lab tests are not typically indicated.
- Glucose determination may be useful if:
- Underlying undiagnosed diabetes is a concern
- There is a concern for associated diabetic ketoacidosis (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 especially in equivocal cases
- 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
Prehospital
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
- The incision should also be wide enough to prevent early skin closure
- Elliptical incision prevents early closure
- Break loculations with gentle exploration
- Irrigate cavity after expressing all pus:
- Irrigation is still recommended but probably not practiced widely
- Packing is controversial and small studies cast doubt on efficacy especially for small abscesses (<5 cm)
- Packing is indicated for the following:
- Larger than 5 cm
- Comorbid medical conditions:
- HIV
- Diabetes
- Malignancy
- Chronic steroid use
- Immunosuppressed
- Abscess location: Face, neck, scalp, hand s/feet, perianal, perirectal, genital
- Antibiotics:
- A recent study demonstrated some value to short- and medium-term cure rates for patients with small (<5 cm) S. aureus abscesses
- The decision to routinely treat these with antibiotics must include cost of treatment and potential side effects of antibiotics
- Shared decision making with the patient is recommended
- Generally accepted indications for antibiotics include:
- 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 remains an option with support from small studies:
- 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 d 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/Strep 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/Strep 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
|
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 d after packing removal
- DaumRS, KumarN, ChambersHF. A trial of antibiotics for smaller skin abscesses . N Engl J Med. 2017;377:e36.
- HankinA, EverettW. Are antibiotics necessary after incision and drainage of a cutaneous abscess?Ann Emerg Med. 2007;50:49-51.
- KesslerDO, KrantzA, MojicaM. Rand omized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department . Pediatric Emerg Care. 2012;28:514-517.
- LaddAP, LevyMS, QuiltyJ. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children . J Pediatr Surg. 2012;45:1562-1566.
- O'MalleyGF, DominiciP, GiraldoP, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary . Acad Emerg Med. 2009;16:470-473.
- Talan , DA , MoranGJ, KrishnadasaA, et al. Subgroup analysis of antibiotic treatment for skin abscesses . Ann Emerg Med. 2018;71:21-30.
- TsoraidesSS, PearlRH, StanfillAB, 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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