Recommended Antibiotic Treatment for Soft Tissue Infections with Abscesses
For soft tissue infections with abscesses, incision and drainage is the primary treatment, with antibiotics indicated only when specific complicating factors are present. 1, 2
Primary Management Approach
- Incision and drainage (I&D) is the cornerstone of treatment for simple abscesses, involving opening the abscess, evacuating all purulent material, and continuing dressing changes until the wound heals by secondary intention 3, 2
- Cultures of the abscess material should be obtained during drainage to guide therapy if antibiotics become necessary 1
- For simple abscesses with minimal surrounding erythema (<5 cm) and minimal systemic signs of infection (temperature <38.5°C, WBC count <12,000 cells/µL, pulse <100 beats/min), antibiotics are unnecessary 3, 1
Indications for Antibiotic Therapy
Antibiotics should be added to I&D only if any of the following are present:
- Severe or extensive disease (multiple sites of infection) or rapid progression with associated cellulitis 3
- Signs and symptoms of systemic illness (fever >38.5°C, heart rate >110 beats/min) 3
- Associated comorbidities or immunosuppression 3
- Extremes of age 3
- Abscess in area difficult to drain completely (face, hand, genitalia) 3
- Associated septic phlebitis 3
- Lack of response to incision and drainage alone 3
- Erythema extending >5 cm beyond the wound margins 3, 1
Antibiotic Selection for Outpatient Treatment
For purulent cellulitis or abscesses requiring antibiotics, empiric therapy should target MRSA:
- Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 DS tablets PO twice daily 3
- Doxycycline: 100 mg PO twice daily 3
- Minocycline: 200 mg initially, then 100 mg PO twice daily 3
- Clindamycin: 300-450 mg PO three times daily (if local resistance rates are low, <10%) 3
- Linezolid: 600 mg PO twice daily (more expensive option) 3, 4
If coverage for both β-hemolytic streptococci and MRSA is desired:
Antibiotic Selection for Inpatient Treatment (Complicated SSTI)
For hospitalized patients with complicated skin and soft tissue infections:
- Vancomycin: 30-60 mg/kg/day IV in 2-4 divided doses 3
- Linezolid: 600 mg IV/PO twice daily 3, 4
- Daptomycin: 4 mg/kg IV once daily 3
- Teicoplanin: 6-12 mg/kg IV every 12h for three doses, then once daily 3
- Clindamycin: 600 mg IV three times daily (if local resistance rates are low) 3
For polymicrobial infections (mixed aerobic-anaerobic):
- Piperacillin-tazobactam: 3.375 g IV every 6h or 4.5 g every 8h 3
- Carbapenems (imipenem, meropenem, ertapenem) 3
- Ceftriaxone 1 g IV daily plus metronidazole 500 mg IV/PO every 8h 3, 5
- Ampicillin-sulbactam 3 g IV every 6h 3
Duration of Therapy
- For outpatients with purulent cellulitis: 5-10 days of therapy, individualized based on clinical response 3
- For hospitalized patients with complicated SSTI: 7-14 days of therapy, based on clinical response 3
- For uncomplicated abscesses requiring antibiotics: less than 5 days may be sufficient after adequate drainage 6
Special Considerations
- Rifampin should not be used as a single agent for MRSA infections as resistance develops rapidly 3
- For recurrent abscesses, consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items 3
- In areas with high MRSA prevalence, empiric coverage should include MRSA-active agents 3
- For human bite infections, amoxicillin-clavulanate is the preferred agent due to coverage of oral flora including Eikenella corrodens 3
Common Pitfalls to Avoid
- Prescribing antibiotics for simple abscesses when not indicated provides no clinical benefit and contributes to antibiotic resistance 1, 7
- Failure to obtain cultures during drainage may lead to inappropriate antibiotic selection if therapy becomes necessary 1
- Using rifampin as monotherapy will rapidly lead to resistance development 3
- Underestimating the importance of adequate drainage - incomplete drainage is a common cause of treatment failure 2, 8