Treatment for Abscesses
The primary treatment for abscesses is surgical incision and drainage, with antibiotics reserved for specific clinical scenarios such as systemic infection, immunocompromised patients, or incomplete source control. 1, 2
Surgical Management
Indications for Incision and Drainage (I&D)
- All abscesses require surgical drainage as the cornerstone of treatment
- Timing of surgery depends on:
- Presence and severity of sepsis
- Patient's immune status
- Size and location of abscess
Surgical Technique
- Make incision as close as possible to the affected area while providing adequate drainage
- Completely evacuate all purulent material
- Irrigate with sterile saline solution
- For perianal abscesses: keep incision close to anal verge to minimize potential fistula length 1
Post-Procedure Care
- For abscesses >5 cm: consider packing to reduce recurrence 3
- For smaller abscesses: packing may be omitted without affecting outcomes 4
- Warm soaks to the area
- Follow-up within 24-48 hours to assess healing
Antibiotic Therapy
Indications for Antibiotics
- Systemic signs of infection (fever, tachycardia)
- Immunocompromised patients
- Incomplete source control
- Significant surrounding cellulitis
- Complex abscesses (perianal, perirectal) 1
Antibiotic Selection
For oral therapy when indicated:
- First-line: Amoxicillin-clavulanic acid 875/125 mg PO every 12 hours 2
- For penicillin-allergic patients: Clindamycin 300-600 mg PO every 8 hours 2, 5
- For suspected MRSA: Trimethoprim-sulfamethoxazole or doxycycline 2
For severe infections requiring IV therapy:
- Vancomycin or teicoplanin for MRSA coverage
- Consider metronidazole for anaerobic coverage, particularly for perianal/perirectal abscesses 6
Duration of Therapy
- Standard duration: 5-7 days when antibiotics are indicated
- Reassess after 48-72 hours for clinical improvement 2
Special Considerations
Small vs. Large Abscesses
- Small abscesses (<4-5 cm): May be managed as outpatient after I&D in immunocompetent patients 1
- Large abscesses (>4-5 cm): May require more aggressive drainage and antibiotic therapy 1
Complex Abscesses
- Perianal/perirectal abscesses: Require specialized surgical approach and often broader antibiotic coverage 1
- Consider imaging (CT, MRI) for complex or recurrent perianal abscesses to assess extent and identify fistulas 1
Monitoring and Complications
Warning Signs Requiring Urgent Attention
- Worsening pain, erythema, or swelling
- Fever or other systemic symptoms
- Inadequate drainage with persistent collection
Potential Complications
- Recurrence (up to 44% for perianal abscesses) 1
- Extension to deeper tissues
- Bacteremia and systemic infection
- Fistula formation (especially with perianal abscesses)
Key Pitfalls to Avoid
- Inadequate drainage is the most common cause of treatment failure
- Antibiotics alone are insufficient for abscess treatment without drainage
- Failure to identify and treat underlying conditions (e.g., inflammatory bowel disease in perianal abscesses)
- Misdiagnosis of deeper or more complex infections
Remember that while antibiotics may penetrate abscess fluid, their efficacy is limited by factors such as low pH and protein binding within the abscess cavity, making surgical drainage the essential first step in treatment 7.