What is the recommended approach for incision and drainage in abscesses with significant erythema (redness) and infection?

Incision and Drainage for Abscesses with Erythema and Infection

Incision and drainage (I&D) should be performed for abscesses even when significant erythema and infection are present, but the extent of surrounding erythema determines whether adjunctive antibiotics are needed. 1

When to Perform I&D

I&D is the primary and essential treatment for all cutaneous abscesses, regardless of surrounding erythema. 1, 2 The key distinction is between simple and complex abscesses:

Simple Abscesses

• Perform I&D alone without antibiotics when erythema and induration are limited to the defined abscess area and do not extend beyond its borders 1
• Simple abscesses must not extend into deeper tissues or have multiloculated extension 1
• Specifically, if surrounding erythema is <5 cm and minimal systemic signs are present (temperature <38.5°C, pulse <100 beats/min), antibiotics are unnecessary 2

Complex Abscesses Requiring I&D Plus Antibiotics

Add antibiotics to I&D when any of the following are present: 1, 2

• Erythema extending >5 cm beyond the abscess margins
• Systemic signs of infection (fever, tachycardia, SIRS criteria)
• Immunocompromised patient status
• Incomplete source control after drainage
• Presence of significant cellulitis surrounding the abscess

Technical Approach to I&D

Procedure Steps

• Use multiple counter incisions for large abscesses rather than a single long incision to prevent step-off deformity and delayed wound healing 1, 2
• Open the abscess, evacuate all infected material, and irrigate the cavity 1
• Obtain cultures of abscess material during drainage to guide therapy if antibiotics become necessary 2
• Consider packing for wounds larger than 5 cm to reduce recurrence 3

Alternative Approach Caveat

Do not use ultrasonographically guided needle aspiration as an alternative to I&D - this approach has only 26% success compared to 80% success with traditional I&D, and success drops further to 8% when MRSA is present 4

Antibiotic Selection When Indicated

When the criteria above mandate antibiotics alongside I&D:

For complex abscesses: Use empiric broad-spectrum coverage targeting Gram-positive, Gram-negative, and anaerobic bacteria 1

For simple abscesses with complicating factors: Target Staphylococcus aureus (including MRSA consideration) and streptococcal species 2, 5

• If MRSA is suspected or prevalent in your area, use glycopeptides or newer antimicrobials rather than beta-lactams 1
• In areas where CA-MRSA is not prevalent and infection is mild, oral beta-lactams may suffice 1

Critical Pitfalls to Avoid

• Never withhold I&D because of surrounding erythema - the presence of infection and erythema are indications to proceed with drainage, not contraindications 1
• Do not prescribe antibiotics for simple abscesses when erythema is confined to the abscess borders - this provides no clinical benefit and promotes resistance 2
• Do not rely on needle aspiration - 60% of attempts yield little or no purulence despite sonographic confirmation of abscess 4
• Recognize that MRSA decreases success rates of both I&D (from 89% to 61%) and needle aspiration (from 55% to 8%), requiring more aggressive management 4

Special Circumstances

For perianal/perirectal abscesses: Prompt surgical drainage is mandatory as undrained abscesses can expand into adjacent spaces and cause systemic infection 1

For recurrent abscesses: Evaluate for underlying conditions such as hidradenitis suppurativa or retained foreign material 2

If significant systemic symptoms are present: Consider hospital admission for intravenous antibiotics and more aggressive management 2