What is the best approach for managing a hard indurated abscess?

Management of Hard Indurated Abscess

The cornerstone of managing a hard indurated abscess is incision and drainage, with antibiotics reserved only for specific high-risk scenarios including systemic signs of infection, extensive surrounding cellulitis (>5 cm), immunocompromised status, or incomplete source control. 1, 2

Initial Assessment and Diagnosis

Clinical Evaluation

• Assess for systemic inflammatory response: Temperature >38.5°C, heart rate >110 beats/minute, or other signs of sepsis 1, 2
• Measure extent of surrounding erythema: Document if cellulitis extends >5 cm beyond abscess margins 1, 2
• Evaluate patient immune status: Immunocompromised patients require more aggressive management 1, 2
• Determine abscess characteristics: Size, location, degree of induration, and fluctuance 3

Imaging Considerations

• Ultrasound or CT with IV contrast may be helpful for deep or complex abscesses to assess extent and guide drainage 4
• Imaging is particularly important for intra-abdominal or deep tissue abscesses where percutaneous drainage may be feasible 4

Primary Treatment: Incision and Drainage

Procedure Approach

• Incision and drainage is the definitive treatment for all abscesses, involving opening the abscess, evacuating infected material, and allowing healing by secondary intention 1, 2, 3
• Obtain cultures during drainage from the abscess material to guide therapy if antibiotics become necessary 1, 2
• For large abscesses, consider multiple counter incisions rather than a single long incision to prevent step-off deformity and delayed wound healing 2

Packing Considerations

• Packing may reduce recurrence in wounds >5 cm but is not universally required 3
• Evidence suggests comparable outcomes with or without packing, and omitting packing reduces post-operative pain and anxiety 5, 6
• If packing is used, remove within 24 hours 5

Antibiotic Therapy: When and What

Indications for Antibiotics (Add ONLY if present)

• Systemic signs of infection: Temperature >38.5°C or heart rate >110 beats/minute 1, 2
• Extensive cellulitis: Erythema extending >5 cm beyond abscess margins 1, 2
• Immunocompromised patient 1, 2
• Incomplete source control after drainage 1, 2
• Presence of SIRS criteria 2

Empiric Antibiotic Selection (if indicated)

For simple cutaneous abscesses:

• Target Staphylococcus aureus (including MRSA) and streptococcal species 1, 2
• First-line options: Trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for MRSA coverage 4
• For methicillin-susceptible S. aureus: First- or second-generation cephalosporin 4
• Adjust based on culture results obtained during drainage 1, 2

For intra-abdominal abscesses with adequate source control:

Immunocompetent, non-critically ill patients:

• Amoxicillin/clavulanate 2 g/0.2 g q8h 4
• Beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 4
• Duration: 4 days if source control adequate 4

Critically ill or immunocompromised patients:

• Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 4
• Beta-lactam allergy: Eravacycline 1 mg/kg q12h 4
• Duration: Up to 7 days based on clinical response 4

Inadequate source control or high risk for ESBL organisms:

• Ertapenem 1 g q24h or Eravacycline 1 mg/kg q12h 4

Septic shock:

• Meropenem 1 g q6h by extended infusion or continuous infusion 4
• Alternatives: Doripenem 500 mg q8h, Imipenem/cilastatin 500 mg q6h, or Eravacycline 1 mg/kg q12h 4

Special Considerations

Percutaneous Drainage for Deep Abscesses

• Percutaneous drainage is preferable to surgical drainage where feasible for well-localized fluid collections 4
• For large diverticular abscesses: Percutaneous drainage combined with antibiotic therapy for 4 days 4
• Antibiotic penetration varies: Piperacillin/tazobactam, cefepime, and metronidazole provide adequate concentrations except in largest abscesses 7

Monitoring and Follow-up

• Evaluate clinical improvement within 48-72 hours: Decreased pain, swelling, and systemic symptoms 1
• If no improvement, reassess for: Inadequate drainage, resistant organisms, or deeper infection 1
• Patients with ongoing infection beyond 7 days warrant diagnostic investigation and multidisciplinary re-evaluation 4

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for simple abscesses without indication – this provides no clinical benefit and contributes to antibiotic resistance 1, 2
• Do not use trimethoprim-sulfamethoxazole as monotherapy for cellulitis due to intrinsic resistance of Group A Streptococcus 4
• Do not delay drainage in favor of antibiotics alone – source control is paramount 4, 2
• Vancomycin and ciprofloxacin have inadequate penetration into most abscesses and should be avoided 7