What is the recommended treatment for a 7-year-old patient presenting to the emergency department with an axillary abscess?

Treatment of Axillary Abscess in a 7-Year-Old Child

The recommended treatment for a 7-year-old with an axillary abscess is incision and drainage under appropriate anesthesia, with antibiotics reserved for specific indications such as significant surrounding cellulitis or systemic symptoms.

Initial Assessment and Preparation

• Evaluate for signs of systemic infection (fever, elevated white blood cell count) which may indicate need for more urgent drainage 1
• Assess the size and depth of the abscess, preferably with bedside ultrasonography to confirm presence, size, and location if the diagnosis is uncertain 2
• Consider the child's ability to cooperate with the procedure to determine appropriate anesthesia approach 1

Anesthesia Options

• For a 7-year-old child, general anesthesia is typically the preferred option due to the need for cooperation and to minimize distress 1

• If general anesthesia is chosen:

  • Procedure should take place in an operating room or anesthetic room with appropriate monitoring 1
  • Local anesthetic should still be used for post-operative pain control 1

• If procedural sedation with local anesthesia is considered:

  • Must be performed by someone trained in conscious sedation, airway management, and pediatric resuscitation 1
  • Full monitoring equipment and resuscitation capabilities must be available 1
  • Intravenous access is mandatory 1

Incision and Drainage Procedure

• Position the child appropriately:

  • Under general anesthesia, position flat with arm on the affected side positioned to expose the axillary area 1
  • For local anesthesia, position with arm behind the head to expose the axillary area 1

• Use sterile technique to prevent wound site infection:

  • Sterile gloves, gown, equipment, and sterile towels after effective skin cleansing 1
  • Large area of skin cleansing is recommended 1

• Make an appropriate incision:

  • Incision should be adequate to allow complete drainage of the abscess 1
  • Avoid using substantial force during the procedure 1
  • For large abscesses, consider multiple counter incisions rather than a single long incision to prevent delayed wound healing 1

Post-Procedure Management

• Consider packing the wound, though evidence for this practice is limited 1
• Recommend warm soaks and appropriate analgesia for post-procedure pain control 3
• Schedule close follow-up to ensure proper healing and to identify any recurrence 3

Antibiotic Therapy

• For simple, uncomplicated abscesses with successful drainage and no systemic symptoms, antibiotics are generally unnecessary 3

• Antibiotics are indicated in the following situations:

  • Presence of significant surrounding cellulitis 1
  • Systemic signs of infection 1
  • Immunocompromised patient 1
  • Incomplete source control 1

• If antibiotics are needed, empiric coverage should include:

  • Coverage for Staphylococcus aureus, including consideration of MRSA in areas where it is prevalent 4
  • Broad-spectrum coverage of Gram-positive, Gram-negative, and anaerobic bacteria if the infection appears complex 1

Special Considerations

• Be aware that axillary abscesses may be caused by community-acquired MRSA, even in otherwise healthy children 4
• If initial treatment fails or if there are recurrent abscesses, consider culture and sensitivity testing to guide antibiotic therapy 4
• For complex or large abscesses, surgical consultation may be appropriate 2