Management of Incision and Drainage with Packing for Abscesses
For most simple abscesses, incision and drainage alone is the primary treatment, and antibiotics are not routinely needed unless there are signs of systemic infection or specific risk factors. 1
Primary Management Approach
- Incision and drainage (I&D) is the cornerstone treatment for abscesses, with complete evacuation of infected material 1
- Wound packing after I&D is a traditional approach, though recent evidence suggests it may not always be necessary for simple abscesses 2
- Gram stain and culture of pus from abscesses are recommended to guide antibiotic therapy if needed, though treatment without these studies is reasonable in typical cases 1
Antibiotic Therapy Decision Algorithm
Antibiotics NOT Required When:
- Simple abscess with successful I&D 1
- Abscess <5 cm in diameter 1
- No systemic inflammatory response syndrome (SIRS) 1
- Immunocompetent patient 1, 3
- No significant surrounding cellulitis 1
Antibiotics ARE Indicated When:
- SIRS present (temperature >38.5°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, WBC >12,000 or <400 cells/µL) 1
- Erythema extending >5 cm from wound edge 1
- Immunocompromised patient 1
- Abscess in difficult-to-drain area (face, hand, genitalia) 1
- Presence of septic phlebitis 1
- Lack of response to I&D alone 1
Antibiotic Selection Based on Anatomical Location
For Skin/Soft Tissue Abscess (Non-Surgical):
- First-line (empiric): TMP-SMX or doxycycline for CA-MRSA coverage 1
- Alternative: Clindamycin 300-450 mg PO TID (provides coverage for both β-hemolytic streptococci and CA-MRSA) 1
- For severe infections: Vancomycin 15-20 mg/kg/dose IV every 8-12 hours 1
For Surgical Site Infections:
Surgery of trunk or extremity away from axilla/perineum:
- Oxacillin/nafcillin 2g every 6h IV
- Cefazolin 0.5-1g every 8h IV
- Cephalexin 500mg every 6h PO
- TMP-SMX 160-800mg PO every 6h 1
Surgery of intestinal or genitourinary tract:
- Single-drug options: Piperacillin-tazobactam 3.375g every 6h IV or ertapenem 1g every 24h IV
- Combination regimens: Ceftriaxone 1g every 24h + metronidazole 500mg every 8h IV 1
Surgery of axilla or perineum:
- Metronidazole 500mg every 8h IV plus either:
- Ciprofloxacin 400mg IV every 12h or
- Levofloxacin 750mg every 24h IV or
- Ceftriaxone 1g every 24h 1
Duration of Therapy
- For simple abscesses requiring antibiotics: 5-10 days 1
- For complicated infections with systemic symptoms: Typically 7-14 days, based on clinical response 1
Special Considerations
- Packing considerations: Traditional teaching advocates packing to prevent premature closure and ensure continued drainage, but recent evidence suggests similar outcomes without packing in uncomplicated cases 2
- High-vacuum wound drainage systems may be an alternative to traditional packing, potentially reducing pain and treatment duration in appropriate cases 4
- For recurrent abscesses: Consider 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items 1
- Methicillin-resistant S. aureus (MRSA) is a common pathogen in community-acquired abscesses and should be considered when selecting empiric therapy 1, 3
Common Pitfalls to Avoid
- Inadequate drainage: Ensure complete evacuation of purulent material; this is more important than antibiotic selection in most cases 1
- Unnecessary antibiotics: Simple abscesses that have been adequately drained often do not require antibiotics, avoiding unnecessary antibiotic exposure 1, 3
- Failure to culture: When antibiotics are indicated, cultures should guide therapy, especially in areas with high MRSA prevalence 1
- Missing underlying conditions: Recurrent abscesses should prompt evaluation for predisposing conditions like diabetes, immunosuppression, or foreign material 1
By following this evidence-based approach to incision and drainage with appropriate antibiotic selection when indicated, optimal outcomes can be achieved while minimizing unnecessary antibiotic use.