From the Guidelines
Empiric antibiotic therapy is not routinely needed after incision and drainage (I&D) of simple cutaneous abscesses in immunocompetent patients. The primary treatment is adequate drainage of the purulent material. However, antibiotics should be considered in specific situations: patients with systemic illness, extensive surrounding cellulitis, immunosuppression, extremes of age, abscess in difficult-to-drain areas, or when MRSA is suspected.
Key Considerations
- When antibiotics are indicated, options include trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily for 5-10 days, clindamycin 300-450 mg orally four times daily for 5-10 days, or doxycycline 100 mg twice daily for 5-10 days, as recommended by the Infectious Diseases Society of America 1.
- These antibiotics provide coverage against MRSA, which is a common cause of skin abscesses.
- For more severe infections or in patients with systemic symptoms, consider intravenous antibiotics like vancomycin, linezolid, or daptomycin.
- The rationale for limited antibiotic use in simple abscesses is that drainage alone is often sufficient to resolve the infection, and unnecessary antibiotic use contributes to antimicrobial resistance.
- Always obtain wound cultures during I&D to guide targeted therapy if the patient doesn't improve with empiric treatment, as suggested by recent guidelines 1.
Antibiotic Choices
- Methicillin-susceptible S. aureus typically is treated with oral penicillinase-resistant β-lactam drugs, such as a first- or second-generation cephalosporin.
- For patients who are allergic to penicillin, or if MRSA is a significant consideration, the alternatives are trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for susceptible isolates.
- Doxycycline can be used safely in children ages 2 years and older when given for durations less than 2 weeks.
- Trimethoprim-sulfamethoxazole should not be used as a single agent in the initial treatment of cellulitis because of the possibility it is caused by group A Streptococcus and the possibility of intrinsic resistance of this organism.
From the Research
Antibiotic Coverage for Abscess after I&D
- The use of antibiotics after incision and drainage (I&D) of an abscess is a topic of debate, with some studies suggesting that antibiotics may not be necessary for uncomplicated cases 2.
- A study comparing ampicillin/sulbactam and cefoxitin in the treatment of cutaneous and other soft-tissue abscesses found that both drugs were effective, with cure or improvement rates of 89.8% and 93.6%, respectively 3.
- Another study found that antibiotic agents are not necessary for uncomplicated subcutaneous abscesses after I&D, and that these cases can be managed safely on an outpatient basis without any increase in morbidity 2.
- A review of wound packing and post-procedural antibiotics for the treatment of skin abscesses found that there is limited evidence to support the use of antibiotics after I&D, and that high rates of clinical cure can be achieved with I&D alone 4.
- A study examining the penetration of antibiotics into experimental intra-abdominal abscesses found that some antibiotics, such as ampicillin/sulbactam and clindamycin, penetrate abscesses to a greater degree than others, such as cefoxitin and ceftriaxone 5.
- The choice of antibiotic should be based on the suspected or confirmed causative pathogens, as well as the patient's individual risk factors and medical history 3, 6.
- In general, antibiotics such as ampicillin/sulbactam, cefoxitin, and clindamycin may be effective options for the treatment of abscesses, although the specific choice of antibiotic will depend on the individual case 3, 6, 5.