Treatment of Abscess
Surgical drainage is the primary and standard treatment for most abscesses, with antibiotics reserved for specific high-risk situations rather than routine use. 1
Primary Treatment Approach
Incision and drainage is the definitive treatment for abscesses, regardless of location or size. 1 This surgical approach should be performed promptly once an abscess is diagnosed, as drainage alone is sufficient for most simple, well-circumscribed abscesses. 1
When Drainage Alone is Sufficient
- Simple, well-delimited abscesses do not require antibiotics after adequate drainage, according to the World Journal of Emergency Surgery. 1
- Most superficial cutaneous abscesses can be managed with incision and drainage under local anesthesia without antibiotic therapy. 2
- For wounds larger than 5 cm, packing may reduce recurrence and complications. 2
Indications for Adding Antibiotic Therapy
Antibiotics should be added to drainage in the following specific situations: 1
- Systemic signs of infection (fever, tachycardia, hypotension) 1
- Immunocompromised patients 1
- Incomplete source control 1
- Significant surrounding cellulitis 1
- Large abscesses (>4-5 cm), particularly intraabdominal abscesses 1
Empiric Antibiotic Selection
When antibiotics are indicated, broad-spectrum coverage targeting Gram-positive, Gram-negative, and anaerobic bacteria is recommended. 3, 1
Appropriate antibiotic options include:
Piperacillin-tazobactam provides adequate coverage for intraabdominal abscesses, including those complicated by rupture or peritonitis, and for cutaneous abscesses caused by beta-lactamase producing organisms. 4 Standard dosing is 3.375 grams IV every 6 hours for 7-10 days. 4
Meropenem is effective for complicated intraabdominal infections and skin/skin structure infections, with demonstrated clinical cure rates of 67-69% for intraabdominal infections and 86% for skin infections. 5
Location-Specific Considerations
Dental Abscesses
- Acute dental abscesses require only surgical drainage without antibiotics. 1
- For dentoalveolar abscesses, incision and drainage followed by amoxicillin for 5 days is recommended. 1
Intraabdominal Abscesses
- Small abscesses (<4-5 cm) may be treated initially with antibiotics alone. 1
- Large abscesses (>4-5 cm) require percutaneous drainage combined with antibiotic therapy. 1
- Piperacillin-tazobactam, cefepime, and metronidazole provide adequate concentrations in most abscesses except the largest ones. 6
Anorectal Abscesses
- Must be drained surgically immediately upon diagnosis. 1
- Add empiric broad-spectrum antibiotics when systemic signs of infection are present. 1
Pulmonary Abscesses
- Over 80% resolve with antibiotics and conservative management alone without requiring drainage. 1
Critical Pitfalls to Avoid
- Do not rely on antibiotics alone for accessible abscesses that can be drained—this delays definitive treatment and risks treatment failure. 1
- Maintain high suspicion for inadequate source control if the patient shows worsening inflammatory signs or the abscess fails to reduce with medical therapy. 1
- Vancomycin and ciprofloxacin achieve inadequate concentrations in most abscesses and should be avoided as monotherapy. 6
- When ≥3 organisms are identified in abscess cultures, clinical failure rates are significantly higher (58% vs 13%), warranting more aggressive management. 6