From the Guidelines
Packing is generally not necessary after incision and drainage (I&D) of most abscesses, and the current recommendation is to avoid routine packing of abscess cavities following I&D, as evidence suggests that packing does not improve outcomes and may actually increase pain and require additional follow-up visits.
Key Points to Consider
- The primary goal of treatment is to promote healing and prevent complications, with a focus on minimizing morbidity, mortality, and improving quality of life.
- After adequate incision, thorough drainage, and breaking up of loculations within the abscess cavity, the wound should be left open to heal by secondary intention.
- A simple sterile dressing should be applied and changed as needed when soiled.
- For very large or complex abscesses with extensive dead space, selective packing may occasionally be considered, but should be removed within 24-48 hours.
- If packing is used, iodoform gauze or plain sterile gauze moistened with saline should be used, and the patient should be instructed on proper wound care, including daily dressing changes and showering to keep the area clean, as suggested by 1.
Rationale for Avoiding Routine Packing
- Natural drainage continues after the procedure, and keeping the wound open without packing allows for better drainage while reducing pain and tissue trauma during dressing changes, ultimately promoting faster healing.
- The use of packing has been shown to be costly and painful, and does not add benefit to the healing process, as noted in 1.
- A Cochrane review included two studies for a total of 64 randomized participants, and found that it is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes, as stated in 1.
Additional Considerations
- The timing of surgery should be based on the presence and severity of sepsis, as suggested by 2.
- In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, outpatient management may be considered, as noted in 2.
- Antibiotic administration may be considered in the presence of sepsis and/or surrounding soft tissue infection or in case of disturbances of the immune response, as suggested by 3.
From the Research
Packing after Incision and Drainage (I&D) of an Abscess
- The decision to pack an abscess after I&D is a topic of debate, with some studies suggesting that packing may not be necessary for small abscesses 4, 5.
- A study published in 2017 found that packing does not affect outcomes for abscesses less than 5 cm in non-diabetic, non-immunocompromised individuals 4.
- Another study published in 2016 found that packing groups had more pain, but there was no difference in treatment failure rates, recurrence rates, or need for secondary interventions in non-packed wounds 5.
- More recent studies have also suggested that packing may be unnecessary for small abscesses, and that loop drainage or needle aspiration may be suitable alternatives to traditional I&D 6, 7.
Considerations for Packing
- The size of the abscess is an important consideration, with smaller abscesses potentially not requiring packing 4, 7.
- The presence of high-risk features, such as immunocompromised status or positive wound cultures for MRSA, may influence the decision to pack or use antibiotics 5, 8.
- The use of antibiotics after I&D is also a topic of debate, with some studies suggesting that they may not be necessary for uncomplicated abscesses, but may be beneficial in certain cases, such as when there is a high risk of recurrence or when the patient has a compromised immune system 5, 8.