What is the recommended treatment for an abscess?

Abscess Treatment

The primary treatment for abscesses is surgical incision and drainage, with antibiotics indicated only in specific circumstances such as systemic symptoms, extensive cellulitis, or immunocompromised states. 1, 2

Types of Abscesses and Initial Management

Superficial/Cutaneous Abscesses

• Incision and drainage (I&D) is the cornerstone of treatment 2, 3
• Most can be safely managed in an ambulatory setting 2
• Local anesthesia is typically sufficient for the procedure 3
• Make an adequate incision that allows complete drainage without damaging adjacent structures 3

Anorectal Abscesses

• Surgical approach with incision and drainage is strongly recommended 1
• Timing of surgery depends on presence and severity of sepsis 1
• For small perianal abscesses in immunocompetent patients without sepsis, outpatient management can be considered 1
• The incision should be kept as close as possible to the anal verge to minimize potential fistula length 1

Diverticular Abscesses

• Size-based treatment approach:
  • Small abscesses (<4-5 cm): Initial trial of antibiotics alone 1
  • Large abscesses (≥4-5 cm): Percutaneous drainage combined with antibiotics 1, 4
  • When percutaneous drainage isn't feasible, antibiotics alone can be tried with careful monitoring 1

Role of Antibiotics

• Antibiotics are NOT routinely needed for simple abscess treatment after I&D 2, 3

• Indications for antibiotics include:

  • Systemic symptoms/sepsis
  • Extensive surrounding cellulitis
  • Immunocompromised patients
  • Certain anatomical locations (e.g., face, hands)
  • Incomplete drainage
  • Diverticular abscesses

• When indicated, antibiotic selection should cover both aerobic and anaerobic organisms 5

• For MRSA coverage (when indicated):

  • Oral options: Trimethoprim-sulfamethoxazole, doxycycline, clindamycin 5
  • IV options: Vancomycin, teicoplanin 5

• For diverticular abscesses, antibiotics are always required as part of treatment 1

Post-Procedure Care

• Warm soaks to the area 3, 6
• Adequate analgesia 3
• Close follow-up (reassess within 48-72 hours) 5
• For wounds >5 cm, packing may reduce recurrence and complications 2
• For smaller wounds, evidence suggests packing may be safely omitted 6

Special Considerations

• Diverticular abscesses: Size is a critical factor in treatment decisions. Abscesses <3 cm can typically be treated with antibiotics alone, while those >4 cm generally require drainage 4

• Antibiotic penetration: The efficacy of antibiotics in abscesses is limited by factors such as low pH, protein binding, and bacterial enzymes 7. This is why drainage remains the primary treatment for most abscesses.

• Recurrent abscesses: Consider extended antibiotic courses, evaluation for underlying conditions, and definitive surgical management 5

Monitoring and Complications

• High recurrence rates (up to 44% for anorectal abscesses) emphasize the need for complete drainage 1
• Risk factors for recurrence include inadequate drainage, loculations, and horseshoe-type abscesses 1
• If no improvement is seen after 2-3 days, consider:
  • Reevaluation of diagnosis
  • Culture and sensitivity testing
  • Alternative antibiotic regimen 5
• Potential complications include damage to adjacent structures, bacteremia, and spread of infection due to inadequate drainage 3

Clindamycin Dosing (When Indicated)

• Adults: 150-300 mg every 6 hours for serious infections; 300-450 mg every 6 hours for more severe infections 8
• Pediatric: 8-16 mg/kg/day divided into 3-4 doses for serious infections; 16-20 mg/kg/day for more severe infections 8
• Should be taken with a full glass of water to avoid esophageal irritation 8
• If significant diarrhea occurs, discontinue therapy 8