Treatment of Abscesses
The primary treatment for most abscesses is surgical incision and drainage, with antibiotics generally only indicated in specific clinical scenarios such as systemic infection, immunocompromised patients, or abscesses with significant surrounding cellulitis. 1
General Principles of Abscess Management
- Surgical drainage is the cornerstone and standard treatment for most abscesses, providing definitive source control 1, 2
- Simple, well-circumscribed abscesses typically do not require antibiotics after adequate drainage 1, 3
- Incision should be made to allow adequate drainage without injuring important anatomical structures 4
- Warm soaks, drains or wicks, and close follow-up are important components of post-drainage care 4
Specific Treatment Approach by Abscess Type
Cutaneous/Superficial Abscesses
- Perform incision and drainage under local anesthesia in the outpatient setting for most simple cutaneous abscesses 2, 4
- Wound packing may be beneficial for abscesses larger than 5 cm to reduce recurrence and complications 2
- Loop drainage technique is preferred over traditional incision and drainage for many superficial abscesses 3
- Wound cultures generally do not improve healing outcomes for simple abscesses 2
Intra-abdominal Abscesses
- Small abscesses (<4-5 cm) can often be treated with antibiotics alone 5, 1
- Larger abscesses (>4-5 cm) typically require percutaneous drainage combined with antibiotic therapy 5, 1
- When percutaneous drainage is not feasible, initial treatment with antibiotics alone can be attempted, but close clinical monitoring is mandatory 5
- For complex or multiloculated abscesses, surgical drainage may be necessary if percutaneous approaches fail 5
Perianal and Perirectal Abscesses
- Prompt surgical drainage is required once diagnosed 5, 1
- Multiple counter incisions are preferred for large abscesses rather than a single long incision 5
- Identify and address any fistula tract during drainage to prevent recurrence 5
Antibiotic Therapy Guidelines
Antibiotics are indicated in the following scenarios 5, 1:
- Presence of systemic signs of infection (fever, leukocytosis)
- Immunocompromised patients
- Incomplete source control
- Significant surrounding cellulitis
- Large abscesses (>4-5 cm), particularly intra-abdominal
When antibiotics are indicated, use broad-spectrum coverage for Gram-positive, Gram-negative, and anaerobic bacteria 5, 1
Consider MRSA coverage in high-risk patients or endemic areas 5
Antibiotic selection should ensure adequate concentration within the abscess cavity 6
- Piperacillin/tazobactam, cefepime, and metronidazole generally achieve adequate concentrations
- Vancomycin and ciprofloxacin often have inadequate penetration into abscess cavities
Special Considerations
- For pulmonary abscesses, most (>80%) can be treated with antibiotics and conservative management without drainage 1
- Breast abscesses unresponsive to systemic antibiotics may benefit from ultrasound-guided serial percutaneous aspiration with local antibiotic injection 7
- Abscesses with ≥3 identified organisms have higher clinical failure rates and may require more aggressive management 6
- Maintain high clinical suspicion for worsening infection; surgical intervention should be performed promptly if the patient shows worsening inflammatory signs or if the abscess does not reduce with medical therapy 5
Pitfalls to Avoid
- Delaying drainage when indicated can lead to expansion of infection and systemic complications 5
- Inadequate drainage or improper incision placement can result in treatment failure 4
- Misdiagnosis of entities that may mimic abscesses (such as mycotic aneurysms) 4
- Underestimating the role of anaerobic bacteria, particularly in perineal abscesses 4