What is the recommended treatment for an abscess that requires incision and drainage?

Treatment of Abscess Requiring Incision and Drainage

Incision and drainage (I&D) is the definitive primary treatment for cutaneous abscesses, and for simple abscesses, I&D alone without antibiotics is sufficient. 1, 2

Immediate Management: Incision and Drainage Technique

• Perform I&D promptly for all cutaneous abscesses as this is the cornerstone of treatment that directly addresses the source of infection 1, 2
• Cover the surgical site with dry sterile gauze only—do not pack the wound as packing causes more pain without improving healing outcomes 2, 3
• Avoid needle aspiration which has only a 25% success rate overall and less than 10% success with MRSA 2

Decision Algorithm: When to Add Antibiotics

Simple Abscesses (No Antibiotics Needed)

For simple abscesses with adequate I&D, antibiotics are not indicated 1, 2, 4

Simple abscesses are characterized by:

• Induration and erythema limited to the defined abscess area 2
• No extension beyond abscess borders or into deeper tissues 2
• Absence of systemic signs of infection 2

Complex Abscesses or High-Risk Situations (Antibiotics Required)

Add antibiotics when any of the following conditions are present: 1, 2

Systemic Inflammatory Response Syndrome (SIRS) Criteria:

• Temperature >38°C or <36°C 2
• Tachypnea >24 breaths/min 2
• Tachycardia >90 beats/min 2
• WBC >12,000 or <4,000 cells/µL 2

Other High-Risk Conditions:

• Severe or extensive disease involving multiple infection sites 1, 2
• Rapid progression with associated cellulitis 1, 2
• Immunocompromised patients or significant comorbidities (diabetes, HIV/AIDS, malignancy) 1, 2
• Extremes of age 1, 2
• Abscess in difficult-to-drain areas (face, hand, genitalia) 1, 2
• Associated septic phlebitis 1, 2
• Lack of response to I&D alone 1, 2

Special Complex Abscess Locations:

• Perianal/perirectal abscesses: Require I&D plus empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria 2, 5
• IV drug injection sites: Require evaluation for endocarditis if systemic signs persist, foreign body removal, and screening for HIV/HCV/HBV 2

Antibiotic Selection for Outpatient Treatment

For CA-MRSA Coverage (Purulent Cellulitis):

First-line oral options include: 1, 2

• Clindamycin 300-450 mg PO three times daily (pediatric: 10-13 mg/kg/dose every 6-8 hours, max 40 mg/kg/day) 1
• TMP-SMX 1-2 double-strength tablets PO twice daily (pediatric: trimethoprim 4-6 mg/kg/dose every 12 hours) 1
• Doxycycline 100 mg PO twice daily (pediatric >8 years: 2 mg/kg/dose every 12 hours) 1
• Minocycline 200 mg once, then 100 mg PO twice daily 1
• Linezolid 600 mg PO twice daily (pediatric: 10 mg/kg/dose every 8 hours, max 600 mg/dose) 1

Duration:

Treat for 5-10 days when antibiotics are indicated 1, 2

Culture Recommendations

• Gram stain and culture of pus are recommended for carbuncles and abscesses, though treatment without these studies is reasonable in typical cases 2
• Consider sampling drained pus in high-risk patients (HIV, immunocompromised), cases with risk factors for multidrug-resistant organisms, recurrent infections, or non-healing wounds 1, 2
• Culture results guide antibiotic adjustment if treatment fails 2

Critical Pitfalls to Avoid

• Do not routinely prescribe antibiotics for simple abscesses after adequate I&D—this contributes to antimicrobial resistance without improving outcomes 1, 2, 4
• Do not use rifampin as single agent or adjunctive therapy for skin abscesses 1, 2
• Do not pack wounds routinely—evidence shows no benefit and increased pain 2, 3
• Do not use fluoroquinolones for MRSA coverage as they are inadequate 2
• For perirectal abscesses, inadequate antibiotic coverage results in a six-fold increase in readmission rates—ensure broad-spectrum coverage including anaerobes 5

Evidence Quality Note

The recommendation against routine antibiotics for simple abscesses is supported by meta-analysis showing no significant improvement in cure rates (88.1% vs 86.0%; OR 1.17,95% CI 0.70-1.95) when antibiotics are added to I&D 4. However, the IDSA guidelines emphasize that this applies only to simple abscesses with adequate drainage 1.