Management of Purulent Drainage from Skin Abrasion (1.5 Weeks Old)
Incision and drainage is the primary treatment required for this infected abrasion with purulent drainage, and you should add oral antibiotics active against MRSA if the patient has fever, tachycardia, tachypnea, or other signs of systemic infection. 1
Initial Assessment and Drainage
The presence of purulent drainage 1.5 weeks after injury indicates an abscess has formed. Your first action is to perform incision and drainage - this is the definitive treatment and takes priority over antibiotics 1. The IDSA guidelines are clear that drainage alone is often sufficient for localized purulent infections.
When to Add Antibiotics
The decision to add antibiotics depends on whether systemic inflammatory response syndrome (SIRS) is present 1:
Add antibiotics if ANY of these are present:
- Temperature >38°C or <36°C
- Heart rate >90 beats/minute
- Respiratory rate >24 breaths/minute
- White blood cell count >12,000 or <4,000 cells/µL
Also add antibiotics for:
- Markedly impaired host defenses (diabetes, immunosuppression)
- Multiple lesions
- Surrounding cellulitis extending beyond the abscess
Antibiotic Selection
If antibiotics are indicated, choose an agent active against MRSA 1:
- Oral options: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole (SMX-TMP)
- These cover both MRSA and typical streptococcal pathogens
Recent evidence shows that adding MRSA-active antibiotics to incision and drainage improves short-term cure rates and reduces new lesions 2, though this benefit is most pronounced when systemic signs are present.
Post-Drainage Wound Care
Do NOT pack the wound - this is a critical point where traditional practice conflicts with evidence. Recent trials demonstrate that packing provides no healing advantage and significantly increases pain 2. Instead:
- Cover with a simple dry sterile dressing 1
- Change dressing daily or when saturated
- For moderate exudate, use absorbent dressings like foam or hydrocolloid 3
Culture Considerations
Obtain culture of the purulent material 1. While treatment can proceed without culture results in typical cases, culture helps if:
- The patient fails to improve
- MRSA prevalence is high in your area
- The patient has recurrent abscesses
Common Pitfalls to Avoid
- Don't rely on antibiotics alone - drainage is essential and antibiotics without drainage will fail
- Don't routinely pack the cavity - this outdated practice increases pain without benefit
- Don't prescribe antibiotics for simple abscesses without SIRS - this contributes to resistance and isn't supported by guidelines
- Don't forget tetanus status - update if needed for any contaminated wound 4
Follow-Up
Arrange follow-up within 48-72 hours to ensure:
- Adequate drainage and wound healing
- Resolution of systemic symptoms if present
- No signs of deeper infection (spreading erythema, worsening pain, fever)
If the abscess recurs at the same site, search for underlying causes like foreign material, pilonidal cyst, or hidradenitis suppurativa 1.