How to manage a cutaneous abscess on the right upper lip and nostril unresponsive to flucloxacillin?

Management of Abscess on Right Upper Lip and Nostril Unresponsive to Flucloxacillin

Incision and drainage is strongly recommended as the primary treatment for the abscess affecting the right upper lip and nostril that has not responded to flucloxacillin therapy. 1

Rationale for Incision and Drainage

• The Infectious Diseases Society of America (IDSA) strongly recommends incision and drainage as the primary treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles with high-quality evidence supporting this recommendation 1
• Flucloxacillin failure indicates the need for a more definitive intervention, as antibiotics alone are often insufficient for abscess treatment
• Drainage provides immediate relief by removing the purulent material and reducing pressure

Procedure Considerations for Facial Abscess

• Special care must be taken due to the sensitive location (upper lip and nostril):
  • Make an incision that follows natural skin lines when possible
  • Ensure adequate anesthesia before proceeding
  • Consider the cosmetic outcome, especially in this visible facial area
  • Be mindful of important facial structures and nerves

Antibiotic Management After Drainage

After performing incision and drainage:

1. Consider changing antibiotic therapy since flucloxacillin has already failed:

   • Options include:
     • Clindamycin (300-450 mg PO TID) - covers MRSA, streptococci, and anaerobes 2
     • Trimethoprim-sulfamethoxazole (1-2 DS tablets PO BID) - good MRSA coverage but limited activity against streptococci 2
     • Doxycycline (100 mg PO BID) - effective against MRSA 2

2. Indications for antibiotic therapy after drainage include:

   • Presence of systemic inflammatory response syndrome (SIRS)
   • Extensive or rapidly spreading cellulitis
   • Immunocompromised state
   • Location in the "danger triangle" of the face (which includes the nose and upper lip) 1, 2

Additional Management Steps

• Obtain cultures during the drainage procedure to guide targeted antibiotic therapy 1
• Consider warm compresses to the area 4-6 times daily for 10-15 minutes 2
• Schedule follow-up within 48-72 hours to assess improvement 2
• If no improvement is seen after drainage and appropriate antibiotic therapy, consider:
  • Reassessment of diagnosis
  • Evaluation for deeper infection
  • Possible imaging studies

Prevention of Recurrence

For patients with recurrent abscesses:

• Consider a 5-day decolonization regimen with:
  • Intranasal mupirocin twice daily
  • Daily chlorhexidine washes
  • Daily decontamination of personal items like towels and sheets 1

Special Considerations

• The facial location (upper lip and nostril) is concerning due to potential for spread to cavernous sinus via facial veins
• This "danger triangle" location warrants more aggressive management and close follow-up
• Inadequate drainage may lead to spread of infection and worsening of symptoms 3
• Antibiotics alone without drainage have been shown to be insufficient for abscess treatment in multiple studies 4, 5

Remember that while antibiotics may be necessary given the facial location, the primary intervention should be adequate incision and drainage, as this is the definitive treatment for abscesses that have failed antibiotic therapy.