Initial Treatment of Abscess or Carbuncle
Incision and drainage is the definitive treatment for abscesses and carbuncles, and should be performed as soon as the diagnosis is made. 1
Immediate Surgical Management
Primary Treatment Approach
- Perform incision and drainage (I&D) for all carbuncles, abscesses, and large furuncles as the cornerstone of treatment with strong recommendation and high-quality evidence 1
- Make the incision as close as possible to the affected area to ensure adequate drainage while avoiding damage to important structures 1
- Thoroughly evacuate all purulent material and probe the cavity to break up any loculations 2
- Cover the surgical site with a dry sterile dressing rather than packing with gauze, as this is more effective for wound healing 2, 3
- Obtain Gram stain and culture of the pus, though treatment without these studies is reasonable in typical uncomplicated cases 1, 2
Timing Considerations
- Young, fit patients without signs of sepsis may have their procedure performed in an ambulatory outpatient setting 1
- Small simple perianal abscesses may be treated under local anesthesia 1
- Emergency drainage is required if the patient has sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis 1
Antibiotic Therapy Decision-Making
When Antibiotics Are NOT Routinely Needed
- Simple abscesses after adequate incision and drainage in immunocompetent patients without systemic signs 1, 4
- Inflamed epidermoid cysts do not require antibiotics 1
When Antibiotics ARE Indicated
Systemic antibiotics should be added as an adjunct to I&D when any of the following are present:
- Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 bpm, or WBC >12,000 or <4,000 cells/μL 3
- Extensive surrounding cellulitis 3
- Multiple lesions 3
- Markedly compromised host defenses (immunosuppression, diabetes) 1, 3
- Carbuncles with formed granuloma (extensive infection requiring systemic therapy) 2
Antibiotic Selection
For Methicillin-Sensitive Staphylococcus aureus (MSSA)
For Methicillin-Resistant Staphylococcus aureus (MRSA) or Suspected MRSA
For Beta-Lactam Allergy
- Clindamycin remains the preferred alternative 1
Duration of Antibiotic Therapy
- 5-10 days for mild to moderate infections after adequate source control 3
Special Populations
Diabetic or Immunocompromised Patients
- Lower threshold for initiating systemic antibiotics 2, 3
- More aggressive treatment approach with closer monitoring 2
- Consider earlier intervention for drainage 2
Critically Ill Patients
Management of Treatment Failure
If No Response Within a Few Days
- Consider adding an aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) 2
- Re-evaluate for resistant organisms based on culture results 2
- Assess for inadequate drainage or loculations requiring repeat procedure 1
Recurrent Carbuncles/Abscesses
Decolonization Protocol
- Mupirocin intranasal application twice daily for 5 days 2, 3
- Daily chlorhexidine baths 2, 3
- Daily decontamination of personal items (towels, sheets, clothes) 2, 3
- Drain and culture recurrent abscesses early in the course 3
Evaluation for Underlying Conditions
- Screen for diabetes mellitus 2
- Assess for immunodeficiency states 2
- Consider colonization with resistant organisms 2
Common Pitfalls to Avoid
- Do not rely on needle aspiration alone - it has only a 25% success rate and is not recommended as definitive treatment 3
- Do not use antibiotics as monotherapy without drainage for formed abscesses or carbuncles 1, 2
- Inadequate drainage is the most common cause of recurrence (up to 44% recurrence rate) 1
- Failure to probe and break up loculations leads to treatment failure 1, 2