What is the treatment plan for a 31-year-old female with bilateral axillary abscesses, containing 5cc of pus, with culture (C/S) results showing Porphyromonas, Prevotella, and Staphylococcus aureus?

Management of Bilateral Axillary Abscesses with Mixed Bacterial Infection

For a 31-year-old female with bilateral axillary abscesses containing Porphyromonas, Prevotella, and Staphylococcus aureus, the optimal treatment plan is surgical incision and drainage followed by broad-spectrum antibiotics targeting both aerobic and anaerobic pathogens.

Initial Management

Surgical Intervention

• Incision and drainage is the cornerstone of treatment for axillary abscesses 1
• The 5x3 cc of pus already evacuated represents initial drainage, but complete source control must be ensured
• Surgical debridement should include:
  • Evacuation of all purulent material
  • Exploration for loculations or deeper extension
  • Removal of necrotic tissue if present

Antibiotic Therapy

• Given the polymicrobial nature (anaerobes Porphyromonas/Prevotella plus S. aureus), broad-spectrum coverage is essential 1, 2
• Recommended empiric antibiotic regimen:
  • Ampicillin-sulbactam (1.5-3.0 g IV every 6-8 hours) 1
  • OR Piperacillin-tazobactam (3.375-4.5 g IV every 6-8 hours) 3, 4
  • Alternative for penicillin allergic patients: Clindamycin (600-900 mg IV every 8 hours) plus a fluoroquinolone 5

Specific Considerations for This Case

Microbiology Considerations

• The presence of Porphyromonas and Prevotella (anaerobes) with S. aureus indicates a complex polymicrobial infection 2
• These organisms are commonly found in skin and soft tissue abscesses, particularly in moist areas like the axilla 2, 6
• More than two-thirds of deep abscesses contain beta-lactamase producing organisms, requiring appropriate antibiotic selection 6

Treatment Duration

• For complicated skin and soft tissue infections: 7-14 days of antibiotics 5
• Initial IV therapy can be switched to oral therapy once clinical improvement is observed:
  • Oral options include: amoxicillin-clavulanate, clindamycin, or trimethoprim-sulfamethoxazole plus metronidazole (for anaerobic coverage) 5

Wound Management After Drainage

• Options for wound management after adequate drainage:
  1. Healing by secondary intention is generally preferred for contaminated wounds to prevent reaccumulation of pus 1
  2. Primary closure is not recommended for contaminated wounds with active infection
  3. Complex reconstruction with flaps is unnecessary for most axillary abscesses unless there is extensive tissue loss

Follow-up Care

Monitoring Response

• Clinical response should be assessed within 48-72 hours 5
• If no improvement is observed, consider:
  • Inadequate drainage requiring repeat surgical intervention
  • Antibiotic resistance
  • Development of complications

Prevention of Recurrence

• Proper hygiene measures:
  • Regular washing with antibacterial soap
  • Avoiding sharing personal items
  • Keeping the area clean and dry 5
• Consider decolonization for recurrent S. aureus infections:
  • Intranasal mupirocin
  • Chlorhexidine body washes 5

Conclusion

Based on the clinical presentation and culture results, the most appropriate treatment plan is option A (Extended antibiotics) combined with surgical drainage and healing by secondary intention. While surgical intervention is essential, the polymicrobial nature of the infection with both anaerobes and S. aureus necessitates appropriate antibiotic therapy. Primary closure (option B) or flap reconstruction (option C) would not be appropriate initial management for an actively infected wound.