Should an abscess be packed after incision and drainage (I and D)?

From the Guidelines

Packing an abscess after incision and drainage (I&D) is not recommended due to lack of evidence supporting its benefits and potential to cause harm, such as increased pain and healthcare expense. The most recent and highest quality study, a Cochrane review 1, found that the use of internal dressings (packing) for the healing of perianal abscess cavities has no clear influence on time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes. Additionally, a subsequent multi-center observational study 1 concluded that packing is costly and painful and does not add benefit to the healing process.

Key Considerations

• The primary treatment of anorectal abscesses remains surgical drainage, with the timing being dictated by the severity and nature of any sepsis 1.
• The incision should be kept as close as possible to the anal verge to minimize the length of a potential fistula, while still providing adequate drainage and avoiding sphincteral damage 1.
• The high recurrence rate of anorectal abscesses, which can be as high as 44% 1, emphasizes the need for a complete and accurate drainage of the abscess.
• Young, fit patients without any signs of sepsis may have their surgery undertaken in an ambulatory setting, and small simple perianal abscesses may be treated under local anesthesia 1.

Clinical Approach

• After performing I&D, the wound should typically be left open to heal by secondary intention without packing.
• Thorough incision, complete drainage, breaking up loculations, and irrigation are usually sufficient for simple abscesses.
• Exceptions where packing may be considered include very large abscesses with significant dead space, pilonidal abscesses, or when there's concern about premature closure of the wound.
• If packing is deemed necessary, it should be removed within 24-48 hours, and the decision should be individualized based on the specific clinical situation, abscess location, size, and patient factors.

From the Research

Abscess Packing after Incision and Drainage (I&D)

• The decision to pack an abscess after I&D is a topic of debate, with some studies suggesting that it may not be necessary for all patients 2, 3.
• A study published in 2016 found that wound packing after I&D did not significantly reduce treatment failure rates, recurrence rates, or the need for secondary interventions, but did increase pain in patients 2.
• Another study published in 2021 noted that packing may be unnecessary for small abscesses, and that alternatives such as antibiotics, needle aspiration, and loop drainage may be suitable for certain types of abscesses 3.
• A survey of emergency medicine providers found that 91% of respondents used packing in the wound cavity after I&D, although this practice may not be evidence-based 4.

Evidence for and Against Abscess Packing

• Some studies have found no significant difference in outcomes between packed and non-packed wounds after I&D 2, 5.
• However, other studies have suggested that packing may be beneficial in certain cases, such as in patients with larger abscesses or those at high risk of complications 3.
• The use of antibiotics after I&D is also a topic of debate, with some studies suggesting that they may improve outcomes in certain patients, but also carry potential risks 6, 5.

Clinical Considerations

• The decision to pack an abscess after I&D should be made on a case-by-case basis, taking into account the size and location of the abscess, as well as the patient's overall health and risk factors 2, 3.
• Clinicians should be aware of the potential benefits and risks of abscess packing and consider alternative treatments, such as antibiotics or needle aspiration, in certain cases 6, 5.