Treatment of Axillary Abscess
Immediate incision and drainage is the essential and definitive treatment for axillary abscess, with antibiotics added only when specific high-risk features are present. 1
Primary Treatment: Incision and Drainage
- Perform incision and drainage immediately for all axillary abscesses, as this is the cornerstone of therapy and often sufficient as monotherapy for uncomplicated cases. 1, 2
- Antibiotics alone without drainage will fail—source control through drainage is mandatory. 1, 3
- Cover the wound with simple sterile gauze rather than packing, as packing increases pain without improving healing outcomes. 1, 2
- Obtain wound culture during drainage to guide subsequent antibiotic therapy if needed. 1, 2
When to Add Antibiotics to Drainage
Add antibiotics when ANY of the following are present:
Systemic Signs of Infection
- Temperature >38.5°C or heart rate >110 beats/minute 1
- Meeting SIRS criteria (temperature >38°C or <36°C, tachycardia >90 bpm, tachypnea >24/min, WBC >12,000 or <4,000) 2
Local Disease Severity
- Extensive cellulitis with erythema extending >5 cm beyond wound margins 1, 2
- Rapid progression with associated cellulitis 1, 2
- Multiple infection sites or severe disease 2
Patient Risk Factors
- Immunocompromised state including diabetes mellitus 1, 2
- Extremes of age 2
- Incomplete drainage or difficult-to-drain location 1, 2
Antibiotic Selection
Outpatient Oral Therapy (5-10 days)
- First-line options: TMP-SMX, doxycycline, or clindamycin 1, 2
- Clindamycin provides dual coverage for both MRSA and β-hemolytic streptococci 1
- In a randomized trial of 786 patients with abscesses ≤5 cm, both clindamycin (83.1% cure) and TMP-SMX (81.7% cure) significantly outperformed placebo (68.9% cure, P<0.001), though clindamycin had more adverse events (21.9% vs 11.1%). 4
Inpatient IV Therapy
- For hospitalized patients with severe infection: vancomycin, linezolid, or daptomycin 1
Monitoring and Follow-Up
- Reassess within 48-72 hours for decreased pain and swelling, resolution of fever, and reduction in erythema. 1
- If no improvement occurs, evaluate for inadequate drainage, resistant organisms, or deeper/more extensive infection. 1
Critical Pitfalls to Avoid
- Do not rely on antibiotics alone without drainage—this approach will fail. 1, 2
- Do not use needle aspiration—success rate is only 25% overall and <10% for MRSA infections. 1, 2
- Do not use rifampin as monotherapy or adjunctive therapy for skin and soft tissue infections. 1, 2
- Do not routinely pack wounds, as evidence shows no benefit and increased pain. 2
- Do not use fluoroquinolones for MRSA coverage, as they are inadequate. 2