Best Antibiotic Treatment for Abscesses
For most abscesses, incision and drainage is the primary treatment, with antibiotics recommended only for specific indications including severe or extensive disease, systemic illness, immunosuppression, extremes of age, difficult-to-drain locations, or lack of response to drainage alone. 1
Primary Management Approach
Simple Abscesses
- Incision and drainage alone is adequate for simple, uncomplicated abscesses 1
- Simple abscesses are defined as those with induration and erythema limited to the defined area of the abscess without extension beyond its borders 1
- Recent evidence from a placebo-controlled trial shows that antibiotics in addition to incision and drainage improve outcomes in simple abscesses, with cure rates of 83.1% for clindamycin and 81.7% for TMP-SMX versus 68.9% for placebo 2
When Antibiotics Are Indicated
Antibiotic therapy should be added to incision and drainage when the abscess is associated with:
- Severe or extensive disease (multiple sites of infection)
- Rapid progression with associated cellulitis
- Signs and symptoms of systemic illness
- Comorbidities or immunosuppression
- Extremes of age (very young or elderly)
- Abscess in difficult-to-drain areas (face, hand, genitalia)
- Associated septic phlebitis
- Lack of response to incision and drainage alone 1
Antibiotic Selection
First-line Options for Outpatient Treatment
Trimethoprim-sulfamethoxazole (TMP-SMX) (1-2 DS tablets PO BID) 1
Tetracyclines (doxycycline 100 mg PO BID or minocycline 200 mg x1, then 100 mg PO BID) 1
- Effective against MRSA but limited activity against streptococci
- Not recommended for children <8 years or pregnant women 1
For Coverage of Both MRSA and β-hemolytic Streptococci
- Clindamycin alone 1
- TMP-SMX or tetracycline plus amoxicillin 1
- Linezolid alone (600 mg PO BID) - more expensive option 1, 4
For Complex or Severe Infections (Inpatient)
- Vancomycin (15-20 mg/kg/dose IV every 8-12 h) 1, 5
- For facial abscesses in diabetic patients: vancomycin plus piperacillin-tazobactam or a carbapenem 5
Special Considerations
Complex Abscesses
- Perianal, perirectal, and abscesses at IV drug injection sites typically require broader coverage
- Empiric broad-spectrum therapy covering Gram-positive, Gram-negative, and anaerobic bacteria is recommended 1
Microbiology Considerations
- S. aureus (including MRSA) and streptococci are the most common pathogens 1, 2, 6
- In a large trial, S. aureus was isolated from 67% of abscess cultures, with MRSA accounting for 49.4% of all isolates 2
- Complex abscesses may involve polymicrobial infections including anaerobes 1
Treatment Duration
- 5-10 days of therapy is typically recommended for most abscesses 1
- Duration should be based on clinical response
- For facial abscesses in diabetic patients, 7-14 days is recommended 5
Important Caveats
- Do not use rifampin as monotherapy or adjunctive therapy for treating skin abscesses due to likely development of resistance 1
- Obtain cultures during drainage to guide antibiotic therapy, especially for complex or recurrent abscesses
- Clindamycin has higher rates of C. difficile-associated disease compared to other oral agents 1
- Penicillin resistance is common in S. aureus isolates from abscesses 6
- Antibiotic penetration into abscess fluid can be limited by low pH, protein binding, and bacterial enzymes 7
The evidence strongly supports that while incision and drainage remains the cornerstone of abscess management, appropriate antibiotic therapy significantly improves outcomes in specific clinical scenarios.