What are the systemic signs and symptoms of an abscess and how is it managed?

Systemic Signs and Symptoms of Abscess and Management

Systemic signs and symptoms of an abscess include fever (>38.5°C), tachycardia (>110 beats/minute), tachypnea (>24 breaths/minute), and leukocytosis (WBC >12,000 cells/μL), which indicate the need for prompt surgical drainage and antibiotic therapy. 1

Systemic Manifestations

• Fever (temperature >38.5°C or <36°C) is a common systemic sign, particularly in deeper or more extensive abscesses 1
• Tachycardia (heart rate >90-110 beats/minute) indicates systemic inflammatory response 1
• Tachypnea (respiratory rate >24 breaths/minute) may develop as part of the systemic inflammatory response 1
• Leukocytosis (white blood cell count >12,000 cells/μL) or leukopenia (<400 cells/μL) suggests systemic infection 1
• Hypotension may occur in severe cases, particularly with staphylococcal toxic shock syndrome 1
• Systemic signs are more common with high (deep) abscesses than with superficial abscesses 1

Local Signs and Symptoms

• Pain is the most common symptom of abscess formation 1
• Swelling, erythema, and induration at the abscess site 1
• Fluctuance and purulent drainage when the abscess is mature 1
• Cellulitis extending beyond the abscess margins (>5 cm) suggests more severe infection 1

Management Algorithm

Assessment

1. Evaluate for systemic signs of infection:

   • Temperature >38.5°C or <36°C
   • Heart rate >110 beats/minute
   • Respiratory rate >24 breaths/minute
   • WBC >12,000 or <400 cells/μL 1

2. Assess local characteristics:

   • Size of erythema and induration (>5 cm suggests more severe infection)
   • Depth and extent of abscess
   • Proximity to vital structures 1

Treatment

For Simple Abscesses (minimal systemic signs):

• Incision and drainage is the primary treatment 1, 2
• Antibiotics are unnecessary if:
  • Erythema <5 cm
  • Temperature <38.5°C
  • WBC <12,000 cells/μL
  • Pulse <100 beats/minute 1
• Wound packing is optional and may be omitted for smaller abscesses (<5 cm) 3

For Complex Abscesses (with systemic signs):

• Prompt surgical drainage is essential 1
• Add antibiotic therapy when:
  • Temperature >38.5°C
  • Heart rate >110 beats/minute
  • Erythema extends >5 cm beyond abscess margins
  • Immunocompromised patient
  • Incomplete source control 1
• Short course of antibiotics (24-48 hours) is usually sufficient 1

Antibiotic Selection:

• For abscesses following operations on intestinal/genital tract:

  • Broad-spectrum coverage for mixed gram-positive, gram-negative, and anaerobic bacteria 1
  • Options include piperacillin-tazobactam, carbapenems, or ceftriaxone plus metronidazole 1, 4

• For abscesses following clean procedures:

  • Coverage for S. aureus (including MRSA consideration) and streptococci 1
  • Options include vancomycin or linezolid if MRSA is suspected 1

Special Considerations

• Perianal and perirectal abscesses require prompt surgical drainage to prevent expansion into adjacent spaces and progression to systemic infection 1

• Abscesses in intravenous drug users may require:

  • Evaluation for endocarditis if systemic signs persist
  • Radiography to rule out foreign bodies
  • Screening for viral infections (HIV, HCV, HBV)
  • Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms 1

• Staphylococcal wound toxic shock syndrome may present with:

  • Deceptively benign wound appearance
  • Early erythroderma and late desquamation
  • Fever, hypotension, abnormal hepatic and renal function
  • Treatment requires opening the incision, culture, and antistaphylococcal therapy 1

Pitfalls and Caveats

• Fever during the first 48 hours after surgery rarely indicates surgical site infection (SSI) and is usually due to non-infectious causes 1
• SSIs that occur within 48 hours are almost always due to S. pyogenes or Clostridium species and require immediate attention 1
• Deep abscesses may have minimal local symptoms but significant systemic manifestations 1
• Incision and drainage of superficial abscesses rarely causes bacteremia, so prophylactic antibiotics are not recommended 1
• Failure to drain an abscess adequately can lead to persistent infection, regardless of antibiotic therapy 1