What is the recommended treatment for a cutaneous abscess?

Treatment of Cutaneous Abscess

For simple cutaneous abscesses, incision and drainage (I&D) is the primary and often sole treatment required, with antibiotics reserved for specific high-risk situations. 1

Simple vs. Complex Abscess Classification

Simple abscesses are defined by:

• Induration and erythema limited to the defined abscess area without extension beyond borders 1
• No extension into deeper tissues or multiloculated spread 1
• Absence of systemic signs of infection 1

Complex abscesses include perianal/perirectal locations, IV drug injection sites, or those with significant surrounding cellulitis 1

Primary Treatment: Incision and Drainage

I&D is the definitive treatment for all cutaneous abscesses and should be performed promptly. 1

Technical considerations:

• Simply covering the surgical site with dry sterile gauze is adequate—wound packing causes more pain without improving healing 1
• Needle aspiration is not recommended (only 25% success rate overall, <10% with MRSA) 1
• For large abscesses, use multiple counter incisions rather than one long incision to prevent step-off deformity 1

When to Add Antibiotics

Antibiotics are NOT needed for simple abscesses treated with adequate I&D alone. 1

Specific indications for adjunctive antibiotics:

Add antibiotics when ANY of the following are present:

• Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or WBC >12,000 or <4,000 cells/µL 1
• Severe or extensive disease involving multiple infection sites 1
• Rapid progression with associated cellulitis 1
• Immunocompromised patients 1
• Extremes of age 1
• Abscess in difficult-to-drain areas (face, hand, genitalia) 1
• Associated septic phlebitis 1
• Incomplete source control 1
• Lack of response to I&D alone 1

Antibiotic Selection

For outpatient empiric coverage of CA-MRSA (when antibiotics are indicated):

First-line oral options:

• Clindamycin 300-450 mg every 6-8 hours (adults); 8-16 mg/kg/day divided into 3-4 doses for serious infections in children 1, 2
• TMP-SMX (trimethoprim-sulfamethoxazole) 1
• Doxycycline or minocycline 1
• Linezolid 600 mg twice daily 1

Duration:

• 5-10 days when antibiotics are used 1

If β-hemolytic streptococci coverage is also needed:

• Clindamycin alone (covers both) 1
• TMP-SMX or tetracycline PLUS a β-lactam (e.g., amoxicillin) 1
• Linezolid alone (covers both) 1

Note: Empirical therapy for β-hemolytic streptococci is likely unnecessary for purulent cellulitis/abscesses 1

Complex Abscesses

For complex abscesses (perianal, perirectal, IV drug injection sites), use I&D plus empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, AND anaerobic bacteria. 1

• Perianal/perirectal abscesses should be drained surgically with identification of fistula tracts 1
• IV drug users require evaluation for endocarditis if systemic signs persist, foreign body removal, and screening for HIV/HCV/HBV 1

Culture Recommendations

Gram stain and culture of pus are recommended for carbuncles and abscesses, but treatment without these studies is reasonable in typical cases. 1

• Cutaneous abscesses typically contain normal regional skin flora 1
• Culture results guide antibiotic adjustment if treatment fails 1

Critical Pitfalls to Avoid

• Do not use rifampin as single agent or adjunctive therapy for skin abscesses 1
• Do not routinely prescribe antibiotics for simple abscesses after adequate I&D—this contributes to resistance without improving outcomes 1
• Do not pack wounds routinely—evidence shows no benefit and increased pain 1
• Do not use fluoroquinolones for MRSA coverage—they are inadequate 1