What is the recommended treatment for incision and drainage of an abscess?

Incision and Drainage of Abscesses: Recommended Treatment Approach

The primary recommended treatment for abscesses is surgical incision and drainage, with timing dictated by the severity of sepsis and patient comorbidities. 1

General Principles of Abscess Management

• Surgical drainage is the cornerstone of abscess management, regardless of location 1
• The incision should be kept as close as possible to the anal verge for perianal abscesses to minimize potential fistula length while ensuring adequate drainage and avoiding sphincter damage 1
• Complete drainage is essential, as inadequate drainage is associated with high recurrence rates (up to 44%) 1
• Incision and drainage is superior to needle aspiration, with recurrence rates of 15% vs 41% respectively 1

Timing of Surgical Intervention

• Emergency drainage is indicated for patients with:
  • Sepsis, severe sepsis, or septic shock
  • Immunosuppression
  • Diabetes mellitus
  • Diffuse cellulitis 1
• In the absence of these factors, surgical drainage should ideally be performed within 24 hours 1

Specific Abscess Management by Location

Perianal and Anorectal Abscesses

• Perianal and ischioanal abscesses: Incision and drainage via the overlying skin 1
• Intersphincteric abscesses: Drainage into the rectal lumen, possibly with limited internal sphincterotomy 1
• Supralevator abscesses: Drainage via rectal lumen (if extension of intersphincteric abscess) or externally via skin (if extension of ischioanal abscess) 1

Simple Superficial Abscesses

• Incision and drainage is the primary treatment, with antibiotics generally not needed 1, 2
• To be considered simple, induration and erythema should be limited to a defined area and not extend beyond abscess borders 1

Complex Abscesses

• Require incision and drainage with adjuvant antibiotic therapy in specific circumstances 1
• Antibiotic therapy is recommended if:
  • Systemic signs of infection are present
  • Patient is immunocompromised
  • Source control is incomplete
  • Significant cellulitis surrounds the abscess 1
• Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria are recommended in these cases 1

Outpatient vs. Inpatient Management

• Young, fit patients without signs of sepsis may have surgery in an ambulatory setting 1
• Small simple perianal abscesses may be treated under local anesthesia 1, 2
• Outpatient management can be considered for immunocompetent patients with small perianal abscesses without systemic signs of sepsis 1

Post-Procedure Care

• The role of wound packing after abscess drainage remains controversial:
  • Common practice includes placing internal dressing (pack) into the cavity for hemostasis and to prevent premature skin closure 1
  • Some evidence suggests that packing may be unnecessary for certain abscesses 3
  • For abscesses larger than 5 cm, packing may reduce recurrence and complications 2
• Warm soaks are recommended as part of post-operative care 4

Common Pitfalls and Caveats

• Risk factors for abscess recurrence include:
  • Inadequate drainage
  • Loculations
  • Horseshoe-type abscess
  • Delayed time from disease onset to incision 1
• Routine imaging after incision and drainage is not required, but follow-up imaging is suggested in cases of:
  • Recurrence
  • Suspected inflammatory bowel disease
  • Evidence of fistula or non-healing wound 1
• Antibiotics are generally unnecessary for simple abscesses but should be considered for complex cases or those with systemic symptoms 1, 4
• Approximately one-third of perianal abscesses may develop a fistula-in-ano, which increases risk of recurrence 5

By following these evidence-based recommendations, clinicians can effectively manage abscesses while minimizing complications and recurrence rates.