What is the recommended treatment for an abscess?

Treatment of Abscesses

For abscesses, incision and drainage (I&D) is the primary treatment, with antibiotics only recommended for specific clinical scenarios such as severe infection, systemic illness, or immunocompromised states. 1

Classification and Treatment Approach

Simple Abscesses

• Definition: Limited induration and erythema confined to the abscess area, not extending beyond its borders
• Treatment:
  • I&D alone is adequate 1
  • No antibiotics needed for uncomplicated, simple abscesses 1

Complex Abscesses

• Definition: Abscesses with any of these features:
  • Severe or extensive disease (multiple sites)
  • Rapid progression with associated cellulitis
  • Systemic illness signs/symptoms
  • Comorbidities or immunosuppression
  • Extremes of age
  • Difficult-to-drain locations (face, hand, genitalia)
  • Associated septic phlebitis
  • Lack of response to I&D alone
• Treatment:
  • I&D plus antibiotic therapy 1
  • Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria 1

Specific Abscess Management

Surgical Management

1. Incision and Drainage Technique:

   • Make incision at the point of maximal fluctuance
   • For large abscesses, use multiple counter incisions rather than a single long incision to prevent delayed wound healing 1
   • Ensure complete drainage of all loculations
   • For perianal abscesses, keep incision as close as possible to anal verge 1

2. Post-I&D Management:

   • For wounds >5 cm, packing may reduce recurrence 2
   • For smaller wounds, evidence suggests packing may be unnecessary and can increase pain 3

Antibiotic Selection (when indicated)

Outpatient Treatment

• For MRSA coverage:
  • Clindamycin 150-300 mg PO every 6 hours (300-450 mg for severe infections) 4, 1
  • TMP-SMX 1
  • Tetracyclines (doxycycline or minocycline) 1, 5
  • Linezolid 1

Inpatient Treatment (for severe infections)

• IV vancomycin 1
• IV/PO linezolid 1

Special Considerations

Perianal and Perirectal Abscesses

• Require prompt surgical drainage 1
• Timing of surgery depends on presence and severity of sepsis 1
• Small perianal abscesses in immunocompetent patients without sepsis may be managed as outpatients 1
• High recurrence rate (up to 44%) emphasizes need for complete drainage 1

Common Pitfalls to Avoid

1. Inadequate drainage: Leading cause of recurrence, especially in horseshoe-type or loculated abscesses 1
2. Inappropriate antibiotic use: Antibiotics alone without I&D will not resolve most abscesses 1
3. Misdiagnosis: Ensure proper differentiation from other conditions like mycotic aneurysms 6
4. Delayed treatment: Undrained anorectal abscesses can expand into adjacent spaces and progress to systemic infection 1
5. Rifampin monotherapy: Not recommended for SSTI treatment 1

Follow-up Recommendations

• Close follow-up for all patients with abscesses
• Consider more frequent monitoring for patients with risk factors for recurrence
• Evaluate for complete resolution and absence of new lesion formation
• For perianal abscesses, follow up to assess for fistula formation

Remember that while antibiotics may not improve primary healing of simple abscesses after I&D, some evidence suggests they may reduce new lesion formation within 30 days 7, 3, though this benefit must be weighed against risks of antibiotic use.