What is the treatment for an arm abscess in an intravenous drug abuser (IVDA)?

From the Guidelines

An arm abscess in an intravenous drug user (IVDA) requires prompt medical attention with incision and drainage (I&D) as the primary treatment, followed by appropriate antibiotic therapy. The recommended empiric antibiotic regimen includes coverage for methicillin-resistant Staphylococcus aureus (MRSA) with vancomycin 15-20 mg/kg IV every 12 hours, or alternatives such as daptomycin 6 mg/kg IV daily or linezolid 600 mg IV/PO twice daily 1. For outpatient treatment after drainage, options include trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily, doxycycline 100 mg twice daily, or clindamycin 300-450 mg four times daily for 7-10 days 1.

Key Considerations

• The abscess should be cultured during drainage to guide targeted antibiotic therapy 1.
• Patients should also be evaluated for complications like endocarditis, osteomyelitis, or bacteremia, particularly if they have fever or systemic symptoms 1.
• Additionally, patients should be offered substance use disorder resources, screening for HIV, hepatitis B, and hepatitis C, and tetanus prophylaxis if indicated 1.
• Abscesses in IVDA patients commonly contain MRSA and other skin flora, but may also include oral flora or anaerobes depending on injection practices, which is why broad initial coverage is important until culture results are available 1.

Treatment Options

• Incision and drainage (I&D) as the primary treatment
• Empiric antibiotic regimen with coverage for MRSA
• Culture of the abscess during drainage to guide targeted antibiotic therapy
• Evaluation for complications and offering of substance use disorder resources and screening for infectious diseases.

From the FDA Drug Label

The following dosage schedule is recommended. ... Serious gynecologic and intra-abdominal infections 2 grams intravenous every 8 hours Meningitis 2 grams intravenous every 8 hours Very severe life-threatening infections, especially in immunocompromised patients 2 grams intravenous every 8 hours ... Uncomplicated pneumonia; mild skin and skin-structure infections 500 mg to 1 gram intravenous or intramuscular every 8 hours

The FDA drug label does not answer the question about the treatment of an arm abscess in an intravenous drug user.

From the Research

Arm Abscess in IVDA

• Arm abscesses are a common complication among individuals who inject drugs intravenously (IVDA) 2, 3, 4, 5
• The main risk factors for abscess formation include skin popping, use of unsterilized needles, and injection of speedball (a mixture of cocaine and heroin) 2
• Abscesses in IVDA can be managed with incision and drainage, and in some cases, may require hospitalization and evaluation for underlying conditions such as endocarditis 6, 3

Treatment Options

• Incision and drainage is the primary treatment for abscesses, and may be performed under local or general anesthesia depending on the size and location of the abscess 6, 3
• Antibiotics may be prescribed in some cases, particularly for high-risk patients or those with signs of infection such as fever and chills 3, 4
• Strategies to prevent abscesses in IVDA include decreasing the frequency of injection drug use, needle sharing, and use of contaminated equipment 4

Complications

• IVDA-related abscesses can lead to serious complications such as endocarditis, sepsis, and amputation 3, 4, 5
• The incidence of tetanus is high among IVDA, and vaccination status should be assessed and updated as necessary 3
• Foreign bodies, such as broken needles, should be ruled out by radiography, and duplex sonography should be performed to identify vascular complications 3