Treatment of Simple Bacterial Abscess of the Right Axilla
For a simple axillary abscess in a 29-year-old male, incision and drainage (I&D) alone is the definitive treatment—antibiotics are not needed unless specific high-risk features are present. 1, 2
Primary Treatment: Incision and Drainage
I&D is the sole necessary treatment for simple abscesses. 1, 2 The procedure should be performed promptly with adequate local anesthesia. 3
After drainage, simply cover the wound with dry sterile gauze—do not pack the wound routinely. 2, 4 Evidence shows wound packing causes more pain without improving healing outcomes or reducing recurrence rates. 2, 4
Needle aspiration should be avoided as it has only a 25% success rate overall and less than 10% success with MRSA. 2
When Antibiotics Are NOT Needed
For this 29-year-old with a simple axillary abscess and adequate I&D, antibiotics are unnecessary. 1, 2 Simple abscesses are defined by:
- Induration and erythema limited to the abscess area without extension beyond borders 2
- No extension into deeper tissues or multiloculated spread 2
- Absence of systemic signs of infection 2
When to Add Antibiotics
Add antibiotics ONLY if any of these high-risk features are present:
Systemic inflammatory response syndrome (SIRS) criteria: 2
- Temperature >38°C or <36°C
- Tachypnea >24 breaths/min
- Tachycardia >90 beats/min
- WBC >12,000 or <4,000 cells/µL
Other high-risk features requiring antibiotics: 1, 2
- Severe or extensive disease involving multiple infection sites
- Rapid progression with associated cellulitis extending beyond the abscess margin
- Immunocompromised state (diabetes, HIV, malignancy, immunosuppressive medications)
- Extremes of age (very young or elderly)
- Difficult-to-drain location (face, hand, genitalia)—though axilla is not typically considered difficult
- Associated septic phlebitis
- Lack of response to I&D alone after 48-72 hours
Antibiotic Selection (If Needed)
If antibiotics are indicated based on the criteria above, empiric coverage for community-acquired MRSA (CA-MRSA) is recommended: 1, 2
First-line oral options for adults: 1
- Clindamycin 300-450 mg PO three times daily 1, 5
- TMP-SMX 1-2 double-strength tablets PO twice daily 1
- Doxycycline 100 mg PO twice daily 1
- Minocycline 200 mg once, then 100 mg PO twice daily 1
Duration: 5-10 days when antibiotics are used. 1
Culture Recommendations
- Gram stain and culture of pus are reasonable but not mandatory for typical cases. 2
- Culture results guide antibiotic adjustment if treatment fails or if the patient has high-risk features. 2
Critical Pitfalls to Avoid
Do not routinely prescribe antibiotics for simple abscesses after adequate I&D—this contributes to antimicrobial resistance without improving outcomes. 1, 2, 4
Do not pack wounds routinely—evidence shows no benefit and increased pain. 2, 4
Do not use rifampin as single agent or adjunctive therapy for skin abscesses. 1
Do not use fluoroquinolones for MRSA coverage as they are inadequate. 2
Ensure adequate incision size to allow complete drainage—inadequate drainage is a common cause of treatment failure. 3, 6