From the Guidelines
For a small perirectal abscess with persistent serous drainage after 10 days of Keflex, I strongly recommend referring the patient to surgery for evaluation rather than prescribing another round of antibiotics. Perirectal abscesses typically require surgical drainage as the definitive treatment, as antibiotics alone are often insufficient to resolve the infection completely 1. The continued drainage suggests that the abscess cavity may not have adequately drained or that there could be an underlying fistula that needs assessment.
Key Considerations
- The primary treatment of anorectal abscesses remains surgical drainage, with the timing being dictated by the severity and nature of any sepsis 1.
- A recent randomized prospective study emphasized the importance of a complete drainage of the perianal abscess, with recurrence rates of 41% following needle aspiration compared to 15% after incision and drainage 1.
- The role of antibiotics is suggested in the presence of sepsis and/or surrounding soft tissue infection or in case of disturbances of the immune response, but the evidence is low 1.
Management Approach
- A colorectal surgeon or general surgeon can perform an examination under anesthesia to properly evaluate the extent of the abscess, drain any remaining collection, and check for fistula formation.
- While waiting for the surgical consultation, the patient should be advised to maintain good perianal hygiene with warm sitz baths 2-3 times daily and gentle cleansing after bowel movements.
- Antibiotics alone may temporarily improve symptoms but typically don't address the underlying problem, which is why surgical evaluation is the appropriate next step for definitive management.
From the Research
Management of Perirectal Abscess
- The patient has a small perirectal abscess and has been treated with Keflex for 10 days, but still has some serous drainage.
- The decision to do another round of antibiotics or refer to surgery for evaluation depends on several factors, including the size and location of the abscess, the patient's overall health, and the presence of any underlying conditions.
Antibiotic Treatment
- According to 2, antibiotic treatment alone can be effective for small abscesses, but the penetration of antibiotics into the abscess cavity can be limited by factors such as low pH, protein binding, and degradation by bacterial enzymes.
- The study 3 compared the efficacy of moxifloxacin and amoxicillin/clavulanate in the treatment of complicated skin and skin structure infections, including abscesses, and found that both treatments had similar clinical success rates.
- However, the study 4 found that moxifloxacin had promising results in the treatment of severe odontogenic abscesses, with a similar time to clinical remission compared to amoxicillin/clavulanic acid.
Surgical Evaluation
- The study 5 suggests that ultrasound-guided incision and drainage (I&D) is a valuable approach for managing abscesses, especially for those that are not clinically evident.
- The study also notes that packing after I&D may be unnecessary for small abscesses, and that antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D for abscesses with certain characteristics.
Considerations for Next Steps
- Given the patient's ongoing serous drainage despite 10 days of antibiotic treatment, it may be necessary to consider further evaluation and treatment, including surgical intervention.
- The decision to do another round of antibiotics or refer to surgery should be based on a thorough evaluation of the patient's condition, including the size and location of the abscess, the presence of any underlying conditions, and the patient's overall health.
- It is also important to consider the potential risks and benefits of each treatment option, including the risk of antibiotic resistance and the potential for surgical complications.