What is the treatment plan for a 31-year-old female with bilateral axillary abscesses, containing Porphyromonas, Prevotella, and Staphylococcus aureus, with 5x3 cm pus evacuated?

Management of Bilateral Axillary Abscesses with Polymicrobial Infection

The primary treatment for bilateral axillary abscesses with Porphyromonas, Prevotella, and Staphylococcus aureus is incision and drainage followed by healing by secondary intention (option D), with appropriate antibiotic coverage for the polymicrobial infection.

Surgical Management

The cornerstone of treatment for abscesses is surgical drainage, which is strongly supported by clinical guidelines:

• Incision and drainage is the most important therapeutic intervention for abscesses 1
• The primary treatment for SSIs (surgical site infections) is to open the incision, evacuate infected material, and continue dressing changes until the wound heals by secondary intention 1
• Complete evacuation of purulent material is essential for effective treatment 2

For this specific case with bilateral axillary abscesses showing puncta, erythema, and significant purulent drainage (5x3 cm), the optimal surgical approach is:

1. Incision and drainage of both axillary abscesses
2. Complete evacuation of all purulent material
3. Healing by secondary intention (option D)

Why secondary intention is preferred:

• Primary closure (option B) is not recommended for contaminated wounds with active infection
• Flap closure (option C) would be excessive and inappropriate for a contaminated wound
• Secondary intention allows for continued drainage and prevents premature closure that could lead to recurrent abscess formation 1

Antibiotic Management

Given the polymicrobial nature of the infection (Porphyromonas, Prevotella with Staphylococcus aureus), antibiotic therapy should be initiated:

• The mixed aerobic (S. aureus) and anaerobic (Porphyromonas and Prevotella) infection requires broad-spectrum coverage 3
• Incisions in the axilla have a significant recovery of gram-negative organisms and require appropriate antibiotic choices 1

Recommended antibiotic regimen:

1. Initial empiric therapy: Clindamycin is an appropriate choice as it covers:

   • Staphylococcus aureus (including MRSA)
   • Anaerobes including Porphyromonas and Prevotella species 4, 3

2. Alternative options if clindamycin cannot be used:

   • Amoxicillin-clavulanate for coverage of both aerobic and anaerobic organisms 2
   • For MRSA coverage: trimethoprim-sulfamethoxazole plus metronidazole (for anaerobic coverage) 1, 2

Duration of Treatment

• Antibiotic therapy should be continued for 5-7 days after incision and drainage 2
• Longer courses (10-14 days) may be needed if there is extensive surrounding cellulitis or systemic symptoms 1
• Follow-up within 48-72 hours is essential to assess response to treatment 2

Additional Considerations

1. Wound care:

   • Simply covering the surgical site with a dry dressing is usually sufficient 1
   • Packing the wound with gauze may cause more pain without improving healing 1
   • Regular cleaning and dressing changes until complete healing

2. Monitoring for complications:

   • Assess for signs of systemic infection (fever >38.5°C, pulse >100 beats/min) 1
   • Watch for spread of infection to adjacent structures 2
   • Monitor for recurrence if drainage is inadequate 2

3. Prevention of recurrence:

   • Good hygiene practices
   • Consider decolonization with intranasal mupirocin if recurrent staphylococcal infections 5

Conclusion

For this 31-year-old female with bilateral axillary abscesses containing Porphyromonas, Prevotella, and Staphylococcus aureus, the optimal treatment plan is:

1. Incision and drainage of both abscesses
2. Healing by secondary intention (option D)
3. Broad-spectrum antibiotics covering both aerobic and anaerobic organisms (clindamycin being a good first choice)
4. Regular follow-up to ensure complete resolution

This approach addresses both the surgical need to evacuate the purulent material and the requirement for appropriate antimicrobial coverage of the polymicrobial infection.