What is the management for an 88-year-old female with a draining left axillary abscess?

From the Guidelines

The patient should be evaluated immediately for the axillary abscess, despite having a scheduled surgical follow-up, and continue with clean dressing changes and monitoring for any signs of worsening infection, such as spreading redness, increased pain, fever, or systemic symptoms. The presence of a significant amount of pus indicates active infection, and given the patient's age, careful assessment is crucial due to age-related immune changes and the proximity of the abscess to lymph nodes 1. Although the patient does not exhibit fever or systemic symptoms, which is reassuring, the natural drainage of the abscess is a positive sign.

The patient should keep the scheduled surgical appointment on Thursday but seek immediate care if symptoms worsen before then. Applying warm compresses to the area for 15-20 minutes several times daily may help with comfort and continued drainage. It is also advisable for the patient to avoid using deodorants, wearing tight clothing, or doing anything that might irritate the area until it is fully healed.

Given the location of the abscess (axilla), which is an area prone to infection by both gram-positive and gram-negative bacteria, empirical antibiotic coverage should be considered if there are signs of systemic infection or if the patient does not improve with incision and drainage alone 1. However, the current guidelines suggest that incision and drainage are the primary treatments for cutaneous abscesses, with antibiotics being considered based on the presence of systemic signs of infection or specific patient risk factors 1.

In this case, since the patient is 88 years old and has an abscess in the axilla, which can be considered an area difficult to drain and is near lymph nodes, careful monitoring and possibly empirical antibiotic therapy should be considered pending culture results, especially if there are signs of systemic illness or the patient's condition worsens 1. The choice of antibiotic should cover common pathogens, including MRSA, given the potential for resistance and the severity of infections caused by this organism 1.

Therefore, the management plan should include:

• Immediate evaluation of the abscess
• Continued clean dressing changes with sterile gauze 2-3 times daily
• Monitoring for signs of worsening infection
• Application of warm compresses for comfort and drainage
• Avoidance of irritants to the area
• Consideration of empirical antibiotic therapy based on clinical judgment and pending culture results, especially if signs of systemic infection develop or the patient's condition does not improve with current management.

From the Research

Patient Presentation

The patient is an 88-year-old female presenting with a draining abscess in her left axilla, with a significant amount of pus discharged during a dressing change. She denies any fever, fatigue, nausea, or vomiting and has a follow-up appointment with surgery scheduled.

Relevant Studies

• The use of prophylactic antibiotics in surgery to prevent morbidity and mortality, as well as reduce hospitalization duration and cost, is discussed in 2.
• Intraoperative interventions for preventing surgical site infections, including the use of prophylactic antibiotics, are reviewed in 3.
• A study on the serum and tissue concentration of single-dose prophylactic ceftriaxone in laparoscopic cholecystectomy found that a single dose of 1g ceftriaxone immediately prior to skin incision is sufficient for preventing surgical site infections in Indian patients 4.
• Antimicrobial formulation and delivery in the prevention of surgical site infection, including the use of oral antibiotics, antiseptic irrigation, and antimicrobial sutures, are discussed in 5.
• The use of antibiotics in cutaneous surgery, including the routes of administration and consideration of cutaneous and distant infections, is reviewed in 6.

Key Findings

• Prophylactic antibiotics can reduce the risk of surgical site infections, as shown in 3.
• The timing of prophylactic antibiotic administration is important, with administration before incision being more effective than after cord clamping 3.
• A single dose of prophylactic ceftriaxone can be sufficient for preventing surgical site infections in certain patient populations 4.
• The use of antimicrobial measures, such as oral antibiotics and antiseptic irrigation, can be effective in reducing surgical site infection rates 5.
• The use of antibiotics in cutaneous surgery should be prudent and based on individual patient risk factors 6.

Potential Treatment Options

• Prophylactic antibiotics, such as ceftriaxone, may be considered to reduce the risk of surgical site infection.
• Antimicrobial measures, such as antiseptic irrigation and antimicrobial sutures, may be used in conjunction with prophylactic antibiotics.
• The patient's individual risk factors, such as age and presence of infection, should be taken into account when determining the best course of treatment.