Wound Packing After Incision and Drainage: Not Standard Practice
Wound packing after incision and drainage is not necessary for most uncomplicated abscesses and causes additional pain without improving healing outcomes. 1, 2
Primary Management Recommendation
- Simply cover the surgical site with a sterile dry dressing after incision and drainage rather than packing the wound cavity 1
- The IDSA guidelines explicitly state that packing increases pain and healthcare costs without improving healing time, reducing recurrence rates, or preventing fistula formation 1, 2
- Multiple randomized controlled trials found no difference in treatment failure rates, recurrence rates, or need for secondary interventions between packed and non-packed wounds 3, 4, 5
Evidence Base
The most recent IDSA guidelines (2014) and supporting research consistently demonstrate:
- Packing is costly, painful, and adds no therapeutic benefit to the healing process 1, 2
- A multi-center observational study of 141 patients concluded packing does not improve outcomes, with recurrence rates up to 44% regardless of packing status 1, 2
- Pediatric studies showed no significant difference in failure rates between packed (70%) and non-packed (59%) groups, but packing caused more pain 4
- One study of 85 pediatric patients found only one recurrence in each group (packed vs. non-packed), confirming safety of the non-packing approach 5
Alternative Approach When Drainage Needed
- Consider placing a catheter or drain into the abscess cavity that drains into an external dressing, leaving it in place until drainage stops 1
- This approach avoids the pain of packing changes while maintaining adequate drainage 1
Post-Procedure Care Instructions
- Begin warm water soaks or sitz baths 24-48 hours after drainage to promote healing 1, 6
- Keep the wound clean and dry initially, then transition to regular warm soaks 2, 6
- Allow the wound to heal by secondary intention (from inside out) - do not allow skin edges to close prematurely 7, 6
If Packing Was Already Placed
- Remove packing within 24 hours and transition to the above care regimen 2, 6
- There is no benefit to prolonged packing beyond initial hemostasis 2
When Antibiotics Are Indicated (Not Routine)
Antibiotics are not routinely needed after adequate drainage unless specific high-risk features are present 7, 6:
- Temperature >38.5°C or heart rate >110 beats/minute 7
- Erythema extending >5 cm beyond wound margins 7
- SIRS criteria present (temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or WBC >12,000 or <4,000 cells/µL) 1
- Markedly impaired host defenses: diabetes, immunosuppression, or surrounding cellulitis 1, 6
When antibiotics are indicated, prescribe agents active against S. aureus including MRSA coverage when appropriate 1
Critical Pitfalls to Avoid
- Inadequate initial drainage is the primary risk factor for recurrence, not absence of packing 1, 2
- Risk factors for recurrence include inadequate drainage, loculations, and delayed time from disease onset to incision 1
- Do not probe for fistulas if one is not obvious, as this causes iatrogenic complications 1
- Recurrence rates range from 15-44% regardless of packing, emphasizing the importance of adequate initial drainage 2, 6
Special Considerations
For surgical site infections specifically (as opposed to simple abscesses):
- The most important therapy is to open the incision and evacuate infected material, continuing dressing changes until healing by secondary intention 7
- Studies of subcutaneous abscesses found little or no benefit for antibiotics when combined with drainage 7
- The single published trial of antibiotic administration for SSIs found no clinical benefit 7