What is the treatment for an infant with multiple abscesses and carbuncles?

Treatment of Multiple Abscesses and Carbuncles in Infants

The primary treatment for multiple abscesses and carbuncles in infants consists of incision and drainage, with systemic antibiotics indicated when there are signs of systemic infection or when the infant has impaired host defenses. 1

Initial Management

• Incision and drainage is the cornerstone of treatment for abscesses and carbuncles in infants, with thorough evacuation of pus and probing of the cavity to break up loculations 1
• After drainage, simply covering the surgical site with a dry sterile dressing is usually the most effective wound management; packing may cause unnecessary pain and does not improve healing 1
• Gram stain and culture of pus from carbuncles and abscesses should be obtained, especially in infants with multiple lesions, though empiric treatment can begin before results are available 1

Antibiotic Therapy

Indications for Systemic Antibiotics

Systemic antibiotics should be added to incision and drainage when:

• The infant shows signs of systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or abnormal white blood cell count 1
• Multiple lesions are present (as in this case) 1
• Extensive surrounding cellulitis is present 1
• The infant has impaired host defenses 1

Antibiotic Selection

• For empiric therapy, choose an antibiotic active against Staphylococcus aureus, the most common pathogen in abscesses and carbuncles 1, 2
• For infants without MRSA risk factors, options include:
  • Clindamycin: 8-16 mg/kg/day divided into 3-4 doses for serious infections; 16-20 mg/kg/day for more severe infections 3
  • First-generation cephalosporins (if MSSA is suspected) 1
• For infants with MRSA risk factors or in areas with high MRSA prevalence:
  • Clindamycin (if local resistance rates are low) 1, 3
  • Trimethoprim-sulfamethoxazole (for infants >2 months of age) 1
• Adjust therapy based on culture and susceptibility results when available 1

Management of Recurrent Abscesses

If the infant experiences recurrent abscesses:

• Early drainage and culture of recurrent lesions 1
• Treat with a 5-10 day course of antibiotics active against the isolated pathogen 1
• Consider decolonization measures including:
  • Chlorhexidine baths 1
  • Mupirocin intranasal application (if old enough) 1
  • Decontamination of personal items such as clothing, towels, and bedding 1
• Evaluate for underlying conditions that may predispose to recurrent infections, particularly neutrophil disorders, as recurrent abscesses in early childhood may indicate an underlying immune deficiency 1

Special Considerations for Infants

• Infants are considered hosts with potentially impaired defenses, warranting a lower threshold for systemic antibiotic therapy 1, 4
• Careful monitoring for signs of systemic illness is essential, as infants may rapidly deteriorate 4
• Dosing of antibiotics must be weight-appropriate and adjusted for the infant's age 3
• For multiple abscesses specifically in infants, systemic antibiotics are generally recommended even after adequate drainage 2, 4

Follow-up

• Close follow-up is essential to ensure resolution of infection and to identify any new lesions 2
• If lesions are not improving with initial therapy, consider:
  • Inadequate drainage
  • Resistant organisms
  • Underlying conditions predisposing to infection 1
• Consider evaluation for neutrophil disorders if abscesses began in early infancy or are recurrent 1