What is the treatment guideline for an abscess with purulent drainage?

Treatment of Abscess with Purulent Drainage

For a cutaneous abscess with purulent drainage, incision and drainage is the primary and definitive treatment, with antibiotics reserved only for specific high-risk conditions. 1

Primary Treatment Approach

Incision and drainage (I&D) is the cornerstone of treatment for all abscesses with purulent drainage. 1, 2 For simple, uncomplicated abscesses in otherwise healthy patients, I&D alone is sufficient without antibiotics. 1

Technical Considerations for I&D:

• The incision should be placed as close as possible to the anal verge (for perianal abscesses) or at the point of maximal fluctuance to minimize potential fistula length while ensuring complete drainage. 2
• Complete drainage is essential—inadequate drainage is associated with recurrence rates as high as 44%. 2
• Wound packing after drainage is controversial and may be omitted. Evidence suggests packing may be costly and painful without adding benefit to healing. 2, 3

When to Add Antibiotic Therapy

Antibiotics are NOT routinely indicated after adequate surgical drainage. 1, 2 However, antibiotic therapy is specifically recommended when the abscess is associated with ANY of the following conditions: 1

Absolute Indications for Antibiotics:

• Severe or extensive disease (multiple sites of infection) 1
• Rapid progression with associated cellulitis 1
• Signs and symptoms of systemic illness or sepsis 1, 2
• Immunosuppression or immunocompromised state 1, 2
• Significant comorbidities (especially diabetes mellitus) 1, 2
• Extremes of age (very young or elderly) 1
• Abscess in difficult-to-drain locations (face, hand, genitalia) 1
• Associated septic phlebitis 1
• Lack of response to I&D alone 1

Antibiotic Selection for Purulent Infections

For outpatients with purulent drainage requiring antibiotics, empirical coverage for community-acquired MRSA (CA-MRSA) is recommended pending culture results. 1 Coverage for β-hemolytic streptococci is likely unnecessary in purulent infections. 1

Oral Antibiotic Options for CA-MRSA Coverage:

• Clindamycin (A-I evidence) 1
• Trimethoprim-sulfamethoxazole (TMP-SMX) (A-II evidence) 1
• Tetracycline (doxycycline or minocycline) (A-II evidence) 1
• Linezolid (A-II evidence) 1

Duration of Therapy:

5 to 10 days of antibiotic therapy is recommended when antibiotics are indicated. 1

Hospitalized Patients with Complicated Infections

For hospitalized patients with complicated skin and soft tissue infections (deeper infections, major abscesses, surgical/traumatic wounds), empirical IV therapy for MRSA should be considered in addition to surgical debridement. 1

IV Antibiotic Options:

• IV vancomycin (A-I evidence) 1
• Linezolid 600 mg IV/PO twice daily (A-I evidence) 1
• Daptomycin 4 mg/kg IV once daily (A-I evidence) 1
• Telavancin 10 mg/kg IV once daily (A-I evidence) 1
• Clindamycin 600 mg IV/PO three times daily (A-III evidence) 1

Duration for complicated infections is 7 to 14 days. 1

Culture and Sampling

Sampling of drained pus should be performed in high-risk patients and/or in the presence of risk factors for multidrug-resistant organism infection. 1, 2 This includes immunocompromised patients, those with healthcare-associated infections, or those who fail initial therapy. 1, 2

Critical Pitfalls to Avoid

• Do NOT use rifampin as single agent or adjunctive therapy for skin and soft tissue infections. 1
• Do NOT probe for fistulas during acute abscess drainage, as this causes iatrogenic complications. 1, 2
• Do NOT delay drainage if imaging is not immediately available when an abscess is clinically suspected. 2
• Do NOT underestimate the extent of infection—ensure complete drainage to prevent recurrence. 2

Timing of Surgical Intervention

Emergency drainage is indicated for patients with sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis. 2 In the absence of these factors, surgical drainage should ideally be performed within 24 hours. 2