Wound Packing After Incision and Drainage of Infected Cysts
Infected cysts do not require wound packing after incision and drainage, as packing increases pain and healthcare costs without improving healing time, reducing recurrence, or preventing fistula formation. 1
Primary Management Approach
Simply covering the surgical site with a sterile dry dressing is the recommended treatment after incision and drainage of infected epidermoid cysts. 1 The Infectious Diseases Society of America (IDSA) 2014 guidelines explicitly state that one small study found packing caused more pain and did not improve healing when compared to just covering the incision site with sterile gauze. 1
Evidence Against Packing
The evidence consistently demonstrates no benefit to wound packing:
A Cochrane review of 64 randomized participants found it unclear whether packing influences time to healing, wound pain, fistula development, or abscess recurrence. 2 Both included studies were at high risk of bias, and the authors concluded the practice remains unproven. 2
A multi-center observational study of 141 patients undergoing incision and drainage with subsequent packing concluded that packing is costly, painful, and does not add benefit to the healing process. 1
Patients in non-packing groups consistently reported lower pain scores (VAS score of 0) compared to packed groups (VAS score of 2). 2
Alternative Management Strategies
If drainage assistance is needed beyond simple gauze coverage:
Place a catheter or drain into the abscess cavity that drains into an external dressing, leaving it in place until drainage stops. 1, 3 This approach avoids the pain of packing changes while maintaining adequate drainage. 1
High-vacuum wound drainage systems reduce pain and treatment time compared to conventional packing, with no recurrent abscesses observed in one pediatric study of 776 patients. 4
Post-Procedure Care
Instruct patients to begin warm water soaks or sitz baths 24-48 hours after drainage to promote healing. 3
Cover the wound with an absorbent dressing and allow patients to manage their own wounds in the community. 2
Critical Pitfalls to Avoid
Inadequate initial drainage is the primary risk factor for recurrence, not absence of packing. 1, 3 The recurrence rate after simple drainage can be as high as 44%, with risk factors including inadequate drainage, loculations, and delayed time from disease onset to incision. 1
Do not probe for fistulas if one is not obvious, as this causes iatrogenic complications. 5
When Antibiotics Are Indicated
Antibiotics are not routinely necessary after adequate incision and drainage. 6 However, prescribe antibiotics active against S. aureus (including MRSA coverage when appropriate) in the following situations:
Presence of SIRS criteria: temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or WBC >12,000 or <4,000 cells/µL. 1
Markedly impaired host defenses, diabetes, immunosuppression, or surrounding cellulitis. 1, 3
Fever >38.5°C persisting after 48 hours of empirical therapy. 1
Special Considerations for Specific Cyst Types
For hepatic cyst infections, drainage may be pursued when there is persistence of temperature >38.5°C after 48 hours on antibiotics, isolation of resistant pathogens, severely compromised immune system, or CT/MRI detecting gas in a cyst. 1 However, caution is advised in polycystic liver disease as infection may spread to adjacent cysts. 1
Wound packing larger than 5 cm may reduce recurrence in some simple abscesses according to one 2022 study, but this contradicts higher-quality guideline evidence and should not be routinely applied to infected cysts. 7