What is the treatment plan for a 31-year-old female with bilateral axillary swellings, painful and red, with 5x3 cm pus evacuated, culture/sensitivity (C/S) showing Porphyromonas, Prevotella, and Staphylococcus aureus?

Treatment Plan for Bilateral Axillary Abscesses with Porphyromonas, Prevotella, and Staphylococcus aureus

The optimal treatment plan for this 31-year-old female with bilateral axillary abscesses involves incision and drainage followed by healing by secondary intention, combined with a 7-14 day course of amoxicillin-clavulanate to target the polymicrobial infection. 1

Surgical Management

1. Incision and Drainage (I&D)

   • I&D is the most important therapeutic intervention for abscesses, especially with polymicrobial infections 1
   • The incision should be made at the point of maximal fluctuance, oriented parallel to natural skin lines to minimize scarring
   • Complete evacuation of all purulent material is essential for effective treatment

2. Wound Management

   • Healing by secondary intention is the preferred approach as it:
     • Allows for continued drainage
     • Prevents premature closure that could lead to recurrent abscess formation
     • Is particularly important in contaminated wounds with active infection 1
   • A dry dressing is usually sufficient; packing the wound with gauze may cause unnecessary pain without improving healing 1

3. Why not primary closure or flap?

   • Primary closure or flap reconstruction is contraindicated in actively infected wounds with polymicrobial infection
   • These approaches would trap bacteria and increase the risk of recurrence and treatment failure

Antibiotic Therapy

1. First-line Treatment

   • Amoxicillin-clavulanate 875/125 mg PO twice daily for 7-14 days 1
   • This provides coverage for both the anaerobic bacteria (Porphyromonas and Prevotella) and Staphylococcus aureus
   • The clavulanic acid component addresses β-lactamase production, which is common in these bacteria 2

2. Alternative Options

   • If penicillin allergy or MRSA is suspected:
     • Clindamycin 300-450 mg PO every 6-8 hours
     • Trimethoprim-sulfamethoxazole (for MRSA) plus metronidazole (for anaerobes)
     • Doxycycline 100 mg PO twice daily 1

3. Duration of Treatment

   • 7-14 days of antibiotics are recommended due to:
     • Bilateral involvement
     • Significant purulence
     • Polymicrobial nature of infection 1
   • Longer course (10-14 days) if extensive surrounding cellulitis or systemic symptoms are present

Follow-up Care

1. Wound Care

   • Regular cleaning and dressing changes until complete healing
   • Patient education on proper wound care techniques

2. Monitoring

   • Reassessment after 48-72 hours to ensure appropriate response to treatment
   • Monitor for signs of systemic infection (fever >38.5°C, pulse >100 beats/min)
   • Watch for spread of infection to adjacent structures 1

Prevention of Recurrence

1. Hygiene Practices

   • Good personal hygiene to prevent recurrence
   • Regular showering with antibacterial soap
   • Clean, dry clothing, particularly in the axillary region

2. Consideration for Decolonization

   • May consider decolonization strategies for recurrent staphylococcal infections 1

Important Considerations

• The polymicrobial nature of this infection (Porphyromonas, Prevotella, and S. aureus) is typical for axillary abscesses and requires broad-spectrum coverage
• β-lactamase production is detected in approximately 38% of Prevotella and Porphyromonas isolates, making amoxicillin-clavulanate a more appropriate choice than amoxicillin alone 3
• Surgical drainage combined with appropriate antibiotics is essential for successful treatment; antibiotics alone are insufficient for abscess management