Why is excision and flap reconstruction not recommended for bilateral axillary abscesses with polymicrobial infection?

Management of Bilateral Axillary Abscesses with Polymicrobial Infection

Excision and flap reconstruction is not recommended for bilateral axillary abscesses with polymicrobial infection because incision and drainage is the primary treatment of choice, with complete evacuation of purulent material and appropriate antibiotic therapy being essential for effective management. 1

Rationale Against Excision and Flap Reconstruction

Primary Concerns

• Radical surgical approaches like excision and flap reconstruction are excessive for standard abscesses and should be reserved for specific conditions:
  • Extensive flap procedures are primarily indicated for chronic, recurrent conditions like hidradenitis suppurativa after medical management has failed 2
  • For acute polymicrobial abscesses, the primary goal is drainage of purulent material, not extensive tissue reconstruction 1

Infection Control Considerations

• Placing a flap in an actively infected field with polymicrobial organisms creates significant risks:
  • Higher likelihood of flap failure due to bacterial contamination
  • Risk of spreading infection to previously unaffected tissue planes
  • Particularly concerning with polymicrobial infections, which may include MRSA, Pseudomonas, or multidrug-resistant organisms 3

Recommended Management Approach

1. Surgical Management

• Incision and drainage is the most important therapeutic intervention for abscesses 1
• The incision should be made at the point of maximal fluctuance, oriented parallel to natural skin lines 1
• Complete evacuation of purulent material is essential 1
• Allow healing by secondary intention to prevent premature closure that could lead to recurrent abscess formation 1

2. Antibiotic Therapy

• Empiric antibiotic coverage should be initiated after obtaining cultures 1
• For polymicrobial infections, coverage should include both aerobic and anaerobic organisms 4
• First-line treatment: Amoxicillin-clavulanate 875/125 mg PO twice daily 1
• Alternative options with MRSA coverage: Clindamycin, trimethoprim-sulfamethoxazole, doxycycline, or linezolid 1
• Duration of therapy: 7-14 days for extensive bilateral involvement with significant purulence 1

3. Wound Care and Follow-up

• Cover the surgical site with a dry dressing 1
• Regular cleaning and dressing changes until complete healing 1
• Close follow-up with reassessment after 48-72 hours 1
• Monitor for signs of systemic infection (fever >38.5°C, pulse >100 beats/min) 3

Special Considerations for Polymicrobial Infections

• Polymicrobial abscesses require antimicrobials effective against both aerobic and anaerobic components 4
• Common organisms in axillary abscesses include:
  • Staphylococcus aureus and Group A beta-hemolytic streptococci (most prevalent aerobes) 4
  • Anaerobic bacteria (found in approximately 23% of axillary abscesses) 5

When Extensive Surgery May Be Considered

Radical excision with flap reconstruction should only be considered in specific circumstances:

• Chronic, recurrent hidradenitis suppurativa that has failed medical management 6, 2
• Cases where there is extensive tissue necrosis requiring debridement 3
• After the acute infection has been controlled and there is no active purulence 3

Conclusion

For bilateral axillary abscesses with polymicrobial infection, the standard of care is incision and drainage with appropriate antibiotic therapy. Excision and flap reconstruction represents overtreatment for acute abscesses and carries unnecessary risks of flap failure and infection spread. Reserve extensive surgical approaches for chronic conditions after the acute infection has resolved.