Abscess Treatment
The primary treatment for abscesses is surgical incision and drainage, with antibiotics only recommended in specific circumstances such as systemic infection, immunocompromised patients, incomplete source control, or significant surrounding cellulitis. 1
Types of Abscesses and Initial Management
Simple Cutaneous Abscesses
- For simple superficial abscesses or boils, incision and drainage alone is the primary treatment, and antibiotics are generally not needed 1
- Simple abscesses are characterized by induration and erythema limited to a defined area without extending beyond its borders 1
- These abscesses do not extend into deeper tissues and are not multiloculated 1
Complex Abscesses
- Complex abscesses (perianal, perirectal, abdominal, or at IV drug injection sites) typically require incision and drainage with adjuvant antibiotic therapy 1
- Antibiotic therapy is recommended when: 1
- Systemic signs of infection are present
- Patient is immunocompromised
- Source control is incomplete
- Significant cellulitis surrounds the abscess
Specific Abscess Management by Location
Perianal and Perirectal Abscesses
- Once diagnosed, anorectal abscesses should be promptly drained surgically 1
- An undrained anorectal abscess can expand into adjacent spaces and progress to systemic infection 1
- The goal of surgical therapy is to drain the abscess expeditiously, identify any fistula tract, and either proceed with primary fistulotomy or place a draining seton 1
- Large abscesses should be drained with multiple counter incisions rather than a single long incision to prevent delayed wound healing 1
Abdominal Abscesses
- Small diverticular abscesses (<4-5 cm) can be treated with antibiotic therapy alone for 7 days 1
- Large diverticular abscesses require percutaneous drainage combined with antibiotic therapy for 4 days 1
- If percutaneous drainage is not feasible:
Antibiotic Selection When Indicated
For Simple Abscesses Requiring Antibiotics
- Empirical coverage for CA-MRSA in outpatients with SSTI may include: 1
- Clindamycin
- Trimethoprim-sulfamethoxazole (TMP-SMX)
- Tetracyclines (doxycycline or minocycline)
- Linezolid
For Complex Abscesses
- Empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria is recommended 1
- For intra-abdominal abscesses, options include: 2
- Piperacillin-tazobactam (3.375 grams IV every six hours)
- Treatment duration typically 7-10 days
Special Considerations
Timing of Surgery
- For anorectal abscesses, timing of surgery should be based on the presence and severity of sepsis 1
- In the presence of sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis, emergent drainage is indicated 1
- In the absence of these factors, surgical drainage should ideally be performed within 24 hours 1
Outpatient vs. Inpatient Management
- Fit, immunocompetent patients with small perianal abscesses without systemic signs of sepsis may be managed in an outpatient setting 1
- Small simple perianal abscesses may be treated under local anesthesia 1
- Hospitalization is recommended for patients with complicated skin and soft tissue infections, including major abscesses 1
Common Pitfalls to Avoid
- Inadequate drainage leading to recurrence (recurrence rates can be as high as 44%) 1
- Failure to identify and address loculations, horseshoe-type abscesses 1
- Delayed incision and drainage, which is associated with higher recurrence rates 1
- Premature closure of the skin without complete drainage 3
- Damage to adjacent structures during incision and drainage 4
Remember that while needle aspiration has been studied as an alternative to incision and drainage for certain abscesses 5, 6, the standard of care remains surgical incision and drainage for most abscesses 3.