What is the appropriate management for a patient presenting with a left cheek abscess and suspected cellulitis?

Management of Left Cheek Abscess with Surrounding Cellulitis

This patient requires immediate incision and drainage of the 10mm rim-enhancing collection combined with empirical MRSA-active antibiotics, as the CT confirms an abscess that mandates surgical drainage as primary treatment, with antibiotics playing a subsidiary role. 1

Immediate Surgical Intervention

Incision and drainage is the primary and essential treatment for this documented abscess. 1 The CT demonstrates a rim-enhancing collection measuring 10 x 10 mm, which represents a drainable abscess requiring procedural intervention before antibiotics can be effective. 1

• The presence of a defined abscess on imaging makes I&D mandatory—antibiotics alone will fail without source control. 1
• Cultures from the abscess fluid should be obtained during drainage to guide subsequent antibiotic therapy, particularly given the previous antibiotic failure. 1

Empirical Antibiotic Selection

Given the previous antibiotic failure and presence of both abscess and surrounding cellulitis, empirical MRSA coverage is required. 1 This patient meets multiple criteria for MRSA-active therapy: purulent infection (abscess), extensive surrounding cellulitis with systemic signs warranting ER presentation, and documented treatment failure. 1

Outpatient Oral Options (if systemically well after drainage):

• Clindamycin 300-450 mg orally every 6 hours provides single-agent coverage for both MRSA and streptococci, eliminating need for combination therapy. 1, 2
• TMP-SMX 1-2 double-strength tablets twice daily PLUS amoxicillin 500 mg three times daily if clindamycin resistance is >10% locally or patient cannot tolerate clindamycin. 1
• Doxycycline 100 mg twice daily PLUS amoxicillin 500 mg three times daily as an alternative combination. 1

Inpatient IV Options (if systemic toxicity present):

• Vancomycin 15-20 mg/kg IV every 8-12 hours is first-line for hospitalized patients with complicated SSTI. 1, 2
• Linezolid 600 mg IV twice daily is equally effective alternative. 1, 2
• Daptomycin 4 mg/kg IV once daily is another A-I evidence option. 1, 2

Treatment Duration

Treat for 5 days if clinical improvement occurs after drainage; extend only if symptoms have not improved within this timeframe. 2 Traditional 7-14 day courses are no longer necessary for uncomplicated cases once adequate source control is achieved. 2

Critical Decision Points for Hospitalization

Admit for IV antibiotics if any of the following are present:

• Systemic inflammatory response syndrome (fever >38°C, tachycardia >90 bpm, tachypnea >24 rpm) 2
• Hypotension or hemodynamic instability 2
• Altered mental status or confusion 2
• Inability to tolerate oral medications 3
• Rapidly progressive infection despite drainage and initial antibiotics 3

Warning Signs Requiring Immediate Escalation

Evaluate urgently for necrotizing fasciitis if any of the following develop:

• Severe pain out of proportion to examination findings 2
• Skin anesthesia or "wooden-hard" subcutaneous tissues 2
• Rapid progression despite appropriate therapy 2
• Bullous changes or skin necrosis 2
• Gas in soft tissues on imaging 2

If necrotizing infection is suspected, initiate vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 3.375-4.5 g IV every 6 hours and obtain emergent surgical consultation. 2

Common Pitfalls to Avoid

• Do not treat with antibiotics alone without drainage—the abscess will not resolve and represents the primary pathology requiring mechanical evacuation. 1, 4
• Do not use beta-lactam monotherapy (like the previous ER antibiotics likely were) for purulent infections—MRSA coverage is essential in abscess-associated cellulitis. 1
• Do not use doxycycline or TMP-SMX as monotherapy—these lack reliable streptococcal coverage and must be combined with a beta-lactam when treating the surrounding cellulitis component. 1, 2
• Do not delay drainage waiting for antibiotics to work—this patient already failed outpatient antibiotics because source control was never achieved. 1

Adjunctive Measures

• Warm compresses and elevation can promote drainage and reduce edema after I&D. 2
• Examine for dental source despite CT showing no significant dental disease—facial abscesses can originate from odontogenic sources. 4
• Assess the right cheek wound noted on CT, as this may represent another site requiring attention or a portal of entry. 4