Abscess Treatment
Incision and drainage is the primary and definitive treatment for cutaneous abscesses, with antibiotics reserved only for specific high-risk situations including surrounding cellulitis, systemic signs of infection (SIRS criteria), or immunocompromise. 1
Primary Treatment: Incision and Drainage
- Incision and drainage alone is sufficient for most uncomplicated abscesses without adjunctive antibiotics, particularly for lesions <5 cm in immunocompetent patients 1, 2
- Simply covering the surgical site with a dry sterile dressing is the most effective wound management—packing causes more pain without improving healing 1
- Ultrasonographically guided needle aspiration is not recommended, with success rates of only 25% overall and <10% for MRSA infections 1
When to Add Antibiotics
Add antibiotics targeting MRSA only when the following criteria are present: 1
Systemic Inflammatory Response Syndrome (SIRS) Criteria:
- Temperature >38°C or <36°C
- Tachypnea >24 breaths/minute
- Tachycardia >90 beats/minute
- White blood cell count >12,000 or <4,000 cells/µL 1
Additional High-Risk Features Requiring Antibiotics:
- Surrounding cellulitis extending beyond the abscess borders 3
- Markedly impaired host defenses or immunocompromise 1
- Penetrating trauma or injection drug use 1, 4
- Known MRSA colonization or prior MRSA infection 4
- Incomplete source control after drainage 3
- Multiple abscesses or rapidly progressive infection 3
Antibiotic Selection When Indicated
Outpatient Oral Regimens (MRSA Coverage):
- Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily for 5-10 days 1, 4
- Doxycycline 100 mg twice daily for 5-10 days 1, 4
- Clindamycin 300-450 mg three times daily only if local MRSA resistance rates are <10% 1, 4
Inpatient IV Regimens (Severe Infection with SIRS):
- Vancomycin 15-20 mg/kg IV every 8-12 hours is the gold standard for hospitalized patients requiring MRSA coverage 1, 4
- Alternative IV options include linezolid 600 mg IV twice daily or daptomycin 4-6 mg/kg IV once daily 1
- For severe infections requiring dual MRSA and streptococcal coverage, use vancomycin plus piperacillin-tazobactam 1, 4
Culture Recommendations
- Gram stain and culture of pus from abscesses are recommended but treatment without these studies is reasonable in typical cases 1
- Cultures are particularly important for recurrent abscesses to guide targeted therapy 1
- Gram stain and culture of inflamed epidermoid cysts are not recommended 1
Management of Recurrent Abscesses
For patients with recurrent S. aureus abscesses: 1
- Drain and culture early in the course of infection 1
- Treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1
- Consider a 5-day decolonization regimen: intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items 1
- Search for local causes such as pilonidal cyst, hidradenitis suppurativa, or foreign material 1
Critical Pitfalls to Avoid
- Never rely on antibiotics alone without adequate drainage—this leads to treatment failure regardless of antibiotic choice 3, 5
- Do not routinely pack abscess wounds—this increases pain without improving outcomes 1
- Avoid using clindamycin if local MRSA resistance exceeds 10% due to inducible resistance concerns 1, 4
- Do not use beta-lactam antibiotics (cephalexin, dicloxacillin) when MRSA is suspected or confirmed—they have no activity against methicillin-resistant organisms 4
- Recognize that TMP-SMX and doxycycline have poorly defined activity against streptococci—if dual coverage is needed for severe infection with cellulitis, use vancomycin plus piperacillin-tazobactam rather than monotherapy 4
Special Populations
Perirectal Abscesses:
- MRSA prevalence reaches 19% in perirectal abscesses and is frequently underrecognized 5
- Culture at the time of drainage is essential to identify MRSA and guide therapy for complex cases 5