What is the recommended treatment for abscess wound care?

Abscess Wound Care Management

Surgical incision and drainage is the primary treatment for abscesses, with antibiotics only recommended in specific clinical scenarios such as systemic infection, immunocompromised patients, or extensive surrounding cellulitis. 1, 2

Diagnosis and Assessment

• Complete physical examination including digital rectal examination for suspected anorectal abscesses 1
• Check for systemic infection signs (fever, tachycardia, hypotension)
• Laboratory tests for patients with suspected systemic infection:
  • Complete blood count
  • Serum creatinine
  • Inflammatory markers (C-reactive protein, procalcitonin, lactates) 1
• Check serum glucose, HbA1c, and urine ketones to identify undetected diabetes mellitus in patients with suspected anorectal abscess 1

Imaging

• Imaging is generally not required for simple, superficial abscesses
• Consider imaging (MRI, CT scan, or endosonography) for:
  • Atypical presentation
  • Suspected deep or complex abscesses (supralevator, complex anal fistula)
  • Suspected perianal Crohn's disease 1

Treatment Algorithm

1. Surgical Management

• Incision and drainage (I&D) is the cornerstone of treatment 1, 2, 3
• Timing of surgery should be based on presence and severity of sepsis 1
• Emergent drainage indicated for:
  • Sepsis/septic shock
  • Immunosuppression
  • Diabetes mellitus
  • Diffuse cellulitis
• In absence of these factors, drainage should ideally be performed within 24 hours 1
• Fit, immunocompetent patients with small perianal abscesses without systemic signs can be managed as outpatients 1

2. Post-Drainage Wound Care

• Simply cover the surgical site with a dry dressing 2
• No clear recommendation can be made regarding wound packing based on available literature 1
  • Some evidence suggests packing may be painful and does not improve healing outcomes 4
  • Consider packing for wounds larger than 5 cm to reduce recurrence 3
• Apply a small amount of topical antibiotic (like bacitracin) 1-3 times daily; may be covered with sterile bandage 5
• Warm soaks can be used to promote drainage 2

3. Antibiotic Therapy

• Antibiotics are NOT routinely recommended for simple drained abscesses 1, 2, 6
• Reserve antibiotics for specific situations:
  • Presence of sepsis or systemic inflammatory response
  • Immunocompromised patients
  • Extensive surrounding cellulitis
  • Inadequate drainage 1, 2

When antibiotics are indicated:

• First-line oral therapy: Amoxicillin-clavulanate 875/125 mg twice daily 2
• For suspected MRSA: Trimethoprim-sulfamethoxazole 1-2 DS tablets twice daily, Clindamycin 450mg four times daily, or Doxycycline 100mg twice daily 2
• First-line parenteral therapy: Piperacillin-tazobactam 3.37g IV every 6-8 hours plus vancomycin, or Clindamycin 600-900mg IV every 8 hours 2
• Duration: 5-10 days when indicated 2

4. Special Considerations for Anorectal Abscesses

• For anorectal abscesses with obvious fistula:
  • Perform fistulotomy at time of drainage only for low fistulas not involving sphincter muscle
  • Place a loose draining seton for fistulas involving sphincter muscle
  • Avoid probing to search for non-obvious fistulas 1

Follow-up and Prevention

• Re-evaluate in 48-72 hours to assess healing progress 2
• Consider complete excision of any underlying cyst once acute inflammation resolves to prevent recurrence 2
• Monitor for complications:
  • Spread of infection to adjacent structures
  • Systemic infection
  • Recurrence (can be as high as 44% if drainage is inadequate) 1
  • Fistula formation 2

Common Pitfalls to Avoid

1. Inadequate drainage leading to high recurrence rates
2. Unnecessary antibiotic use for simple drained abscesses
3. Failure to identify and properly manage underlying fistulas in anorectal abscesses
4. Missing systemic signs that would indicate need for more aggressive management
5. Probing for non-obvious fistulas, which can cause iatrogenic complications 1