What is the recommended wound care for a subcutaneous abscess following a bedside Incision and Drainage (I & D)?

Wound Care for Subcutaneous Abscess Following Bedside I&D

After incision and drainage (I&D) of a subcutaneous abscess, the most important wound care is to leave the wound open and perform regular dressing changes until the wound heals by secondary intention, without routine use of antibiotics or packing. 1

Primary Management Principles

• The cornerstone of abscess treatment is adequate incision and drainage with complete evacuation of purulent material 1
• After drainage, wounds should be left open to heal by secondary intention with regular dressing changes 1
• Routine wound packing is not necessary and may cause increased pain without improving outcomes 2, 3
• Antibiotics are generally unnecessary for uncomplicated abscesses after adequate drainage 1, 4

Recommended Wound Care Protocol

Immediate Post-I&D Care

• Ensure complete evacuation of all purulent material 1
• Irrigate the wound cavity to remove debris and residual purulent material 1
• Apply a clean, sterile dressing over the wound 1

Ongoing Wound Care

• Perform daily dressing changes with clean technique 1
• Apply warm soaks to the area 3-4 times daily to promote drainage and healing 3
• Monitor for signs of inadequate drainage or worsening infection 1
• Continue wound care until complete healing occurs by secondary intention 1

Evidence Against Routine Wound Packing

Research shows that packing may not be necessary for most uncomplicated abscesses:

• A randomized controlled trial found no difference in recurrence rates or need for secondary interventions between packed and non-packed wounds 3
• Packing can increase patient discomfort and anxiety without improving outcomes 2, 3
• Omitting packing simplifies wound care and may improve patient compliance 3

Antibiotic Considerations

Antibiotics should be reserved for specific situations:

• Presence of systemic inflammatory response (temperature >38.5°C, heart rate >110 beats/minute) 1
• Extensive surrounding cellulitis (>5 cm of erythema extending beyond wound margins) 1
• Immunocompromised patients 1
• Diabetic patients or those with significant comorbidities 1
• Inadequate response to drainage alone 1

When antibiotics are indicated, selection should be guided by:

• Local patterns of antimicrobial resistance 1
• Results of wound culture and Gram stain if obtained 1
• Coverage for common pathogens including MRSA in high-risk patients 1

Follow-up Recommendations

• Routine follow-up within 48-72 hours to assess wound healing 1
• Instruct patients to return sooner if they develop:
  • Increasing pain, swelling, or redness 1
  • Fever or systemic symptoms 1
  • Purulent drainage that increases or changes in character 1
  • Failure of symptoms to improve within 48 hours 1

Special Considerations

• For large abscess cavities, consider loose wicking material to maintain drainage pathway in the first 24-48 hours 2
• Primary closure after I&D is generally not recommended for contaminated wounds 1
• For recurrent abscesses, consider underlying causes such as foreign body, pilonidal disease, or hidradenitis suppurativa 1
• In immunocompromised patients, more aggressive wound care and antibiotic therapy may be warranted 1

Common Pitfalls to Avoid

• Inadequate initial drainage (ensure complete evacuation of all loculations) 1
• Premature wound closure before complete resolution of infection 1
• Unnecessary use of antibiotics for adequately drained, uncomplicated abscesses 1, 4
• Failure to recognize and address systemic signs of infection that would warrant antibiotics 1
• Overlooking the possibility of a deeper or more complex infection requiring additional intervention 1