Treatment of Sepsis with Abscess
The treatment of sepsis with abscess requires immediate source control through drainage of the abscess within 12 hours of diagnosis, along with broad-spectrum antibiotics administered within 1 hour of recognition of sepsis. 1
Initial Management
Immediate Actions
Resuscitation
Source Control
- Obtain imaging studies to identify the abscess location and characteristics 1
- Perform drainage of the abscess within 12 hours of diagnosis 1
- Choose the least physiologically disruptive method (percutaneous drainage preferred over surgical when feasible) 1
- Remove any potentially infected intravascular devices after establishing alternative access 1
Antimicrobial Therapy
Antibiotic Selection
Empiric Therapy Options
For septic shock: Use combination therapy with at least two antibiotics of different classes targeting the most likely pathogens 1
For sepsis without shock: Monotherapy may be sufficient 1
- Meropenem has shown 67-98% microbiologic eradication rates in intra-abdominal infections 4
Antibiotic Considerations
- Dosing should be optimized based on pharmacokinetic/pharmacodynamic principles 1, 5
- Higher initial doses of hydrophilic antibiotics are often needed due to increased volume of distribution in sepsis 5
- Consider extended or continuous infusion of beta-lactams to improve target attainment 5
Specific Abscess Management
Anorectal Abscess
- Surgical incision and drainage is strongly recommended 1
- Timing of surgery depends on presence and severity of sepsis 1
- Antibiotics are indicated in patients with:
- Sepsis
- Surrounding soft tissue infection
- Immunocompromise 1
Skin and Soft Tissue Abscesses
- Incision and drainage is the primary treatment 1
- Additional antibiotics recommended for:
- Severe or extensive disease
- Rapid progression with cellulitis
- Signs of systemic illness
- Immunosuppression
- Difficult-to-drain locations (face, hand, genitalia)
- Septic phlebitis 1
Ongoing Management
Antibiotic Duration and De-escalation
- Reassess antibiotics daily for potential de-escalation 1
- De-escalate within the first few days based on clinical improvement and culture results 1
- Standard duration is 7-10 days for most serious infections 1
- Longer courses (>10 days) may be needed for:
- Slow clinical response
- Undrainable foci of infection
- S. aureus bacteremia
- Fungal or viral infections
- Immunocompromise 1
- Shorter courses may be appropriate with rapid resolution following source control 1
Monitoring Response
- Daily assessment of clinical status 1
- Consider procalcitonin levels to guide antibiotic duration 1
- Monitor for adequate source control and need for repeat intervention 1
Special Considerations
Antibiotic Penetration into Abscesses
- Antibiotic penetration into abscesses can be limited by:
- Abscess maturation
- Low pH environment
- Protein binding
- Bacterial enzyme degradation 6
- Some antibiotics achieve better abscess penetration than others:
- Piperacillin/tazobactam, cefepime, and metronidazole generally provide adequate concentrations
- Vancomycin and fluoroquinolones often have inadequate levels in abscesses 7
Multidrug-Resistant Organisms
- Consider risk factors for MDR pathogens when selecting empiric therapy 3
- Obtain cultures from abscess fluid to guide targeted therapy 7
- Polymicrobial infections with ≥3 organisms are associated with higher failure rates 7
Pitfalls to Avoid
- Delaying source control (drainage) - this is critical for successful treatment 1, 8
- Inadequate initial antibiotic dosing - standard dosing often insufficient in sepsis 5
- Failing to de-escalate antibiotics when appropriate - increases risk of resistance 1, 3
- Overlooking the need for repeat drainage if clinical improvement stalls 1
- Stopping antibiotics too early in complicated cases (undrainable foci, immunocompromise) 1
By following this approach with prompt source control and appropriate antimicrobial therapy, outcomes for patients with sepsis due to abscess can be significantly improved.