Procedure Note Template for Incision and Drainage of Acute Cutaneous Abscess
For simple cutaneous abscesses, incision and drainage is the definitive treatment, and antibiotics are unnecessary after adequate drainage unless specific high-risk features are present. 1, 2
Patient Demographics & Identification
- Full name, medical record number, date of birth
- Date and time of procedure
- Attending physician and assisting personnel 2
Pre-Procedure Assessment
Chief Complaint & History
- Duration of abscess symptoms (pain, swelling, erythema) 1
- History of fever, chills, or systemic symptoms 1
- Prior abscess episodes or recurrent infections 2
- Immunocompromising conditions: diabetes mellitus (check HbA1c and glucose), HIV status, immunosuppressive medications, or chronic steroid use 1, 2
- History of intravenous drug use (critical red flag for necrotizing infection risk) 3
Physical Examination Findings
- Vital signs: Temperature, heart rate, blood pressure, respiratory rate 1
- Abscess characteristics: Location, size (measure in cm), fluctuance, surrounding erythema (measure extent in cm from abscess margin), induration, warmth 1, 2
- Systemic signs: Document presence or absence of sepsis criteria (temperature >38.5°C or <36°C, heart rate >90-110 bpm, respiratory rate >24/min, WBC >12,000 or <4,000 cells/µL) 1, 2
Laboratory & Imaging (When Indicated)
- Routine labs are NOT required for simple abscesses 2
- Order CBC, CRP, glucose, HbA1c, and creatinine only if: systemic infection suspected, immunocompromised status, or diabetes screening needed 1, 2
- Imaging (ultrasound, CT, or MRI) reserved for: atypical presentation, suspected deep/complex abscess, perianal location with possible fistula, or concern for necrotizing infection 1, 4
Indications for Procedure
- Fluctuant cutaneous abscess confirmed by clinical examination or ultrasound 2
- All cutaneous abscesses, large furuncles, and carbuncles require drainage regardless of size 2
Informed Consent
- Risks discussed: bleeding, infection, recurrence (up to 44% with inadequate drainage), scarring, need for repeat procedures, rare risk of necrotizing infection 4, 3
- Benefits: source control, pain relief, prevention of systemic spread 1
- Patient verbalized understanding and provided written/verbal consent 2
Procedure Details
Anesthesia
- Local anesthetic infiltration: lidocaine 1% with or without epinephrine, administered via field block around abscess (NOT over the roof to avoid spreading infection) 5
- Consider procedural sedation or general anesthesia for large, deep, or perianal abscesses 6
Technique
- Incision placement: Linear incision as close as possible to the anal verge for perianal abscesses to minimize fistula length; for other sites, place incision over point of maximal fluctuance 4
- For large abscesses (>5 cm): Use multiple counter-incisions rather than a single long incision to prevent step-off deformity and delayed healing 2, 4
- Drainage: Express all purulent material, break up loculations with finger or instrument, irrigate cavity (optional, used by 48% of providers) 5
- Exploration: Probe cavity gently to assess depth and rule out deeper extension; do NOT aggressively probe for fistula if none is apparent (risk of iatrogenic injury) 4
- For perianal abscesses with obvious low fistula (not involving sphincter): Perform fistulotomy at same session; if sphincter involved, place loose draining seton only 4
Specimen Handling
- Routine wound cultures are NOT indicated for simple abscesses 2, 5
- Send pus culture only if: immunocompromised, recurrent abscess, MRSA suspected, systemic infection present, or complex/deep abscess 2, 7
- Label specimen with patient identifiers, site, and date 2
Post-Procedure Care
Wound Management
- Packing: Controversial; 91% of providers pack wounds, but evidence suggests packing may be costly and painful without added benefit 4, 5
- Wound care instructions: daily dressing changes, keep clean and dry, monitor for worsening erythema or drainage 2
Pain Management
- Oral analgesics: ibuprofen 600 mg every 6 hours or acetaminophen 1000 mg every 6 hours 5
- Short-course opioids (e.g., oxycodone 5 mg every 6 hours PRN) only if severe pain; 76% of providers use narcotics 5
Antibiotic Therapy Decision Algorithm
DO NOT prescribe antibiotics if ALL of the following are true:
- Temperature <38.5°C 1, 2
- Heart rate <100-110 bpm 1, 2
- WBC <12,000 cells/µL 1, 2
- Erythema/induration <5 cm from abscess margin 1, 2
- Immunocompetent patient 1, 2
- Adequate drainage achieved 1, 2
PRESCRIBE antibiotics if ANY of the following are present:
- Systemic signs: temperature >38.5°C, heart rate >110 bpm, or SIRS criteria 1, 2
- Extensive cellulitis (erythema >5 cm from margin) 1, 2
- Immunocompromised status (diabetes, HIV, immunosuppressive therapy) 1, 2
- Incomplete source control or multiloculated abscess 2
- High-risk location: perianal, axillary, IV drug injection site 2
- Recurrent abscess 2
Antibiotic Regimens (When Indicated)
For simple trunk/extremity abscesses:
- First-line: Clindamycin 300-450 mg PO every 6-8 hours for 7 days (83% cure rate, superior to alternatives) 2
- Alternative: TMP-SMX DS (160/800 mg) PO twice daily for 7 days 2
- Penicillin allergy: Doxycycline 100 mg PO twice daily for 7 days 2
For axillary or perianal abscesses (polymicrobial coverage needed):
- Clindamycin 300-450 mg PO every 6-8 hours PLUS ciprofloxacin 500 mg PO twice daily for 7 days 2
- Alternative: Cephalexin 500 mg PO every 6 hours PLUS metronidazole 500 mg PO every 8 hours for 7 days 2
For severe systemic infection or sepsis (IV therapy):
- Vancomycin 30 mg/kg/day IV divided every 12 hours PLUS piperacillin-tazobactam 3.375 g IV every 6 hours 2, 4
- Alternative: Clindamycin 600-900 mg IV every 8 hours PLUS ciprofloxacin 400 mg IV every 12 hours 2
Critical caveat: TMP-SMX does NOT cover anaerobes; add metronidazole for perianal/buttock abscesses 2. Metronidazole alone is NEVER appropriate (lacks S. aureus coverage) 2.
Follow-Up Plan
Routine Follow-Up
- Return in 48 hours for wound check and packing removal (if used) 5, 6
- Earlier return if: fever, worsening pain, spreading erythema, purulent drainage, or systemic symptoms 2
Red Flags Requiring Immediate Return
- Fever >38.5°C, chills, or rigors 2
- Rapidly spreading erythema or darkening skin (concern for necrotizing fasciitis or DVT) 8, 3
- Severe pain out of proportion to exam (necrotizing infection) 3
- Crepitus, bullae, or skin necrosis (necrotizing fasciitis) 1, 3
Long-Term Management
- If recurrent abscesses: consider MRSA decolonization with intranasal mupirocin twice daily for 5 days and chlorhexidine body washes 2
- Screen for undiagnosed diabetes mellitus (check HbA1c and fasting glucose) 1
- For perianal abscesses: follow-up imaging or surgical evaluation only if recurrence, non-healing wound, or suspected fistula/Crohn's disease 4
Estimated Blood Loss & Complications
- Estimated blood loss: typically <10 mL 2
- Immediate complications: none (or document any bleeding, vasovagal episode, etc.) 2
Disposition
- Discharged home in stable condition with wound care instructions, pain management, antibiotic prescription (if indicated), and follow-up appointment 2
- Admitted if: sepsis, necrotizing infection suspected, immunocompromised with systemic signs, or inadequate outpatient support 1
Critical Pitfalls to Avoid
- Never delay drainage for imaging or lab results in clinically obvious abscess 4
- Never rely on antibiotics alone without drainage—this leads to treatment failure and recurrence 2, 4
- Never miss necrotizing infection: IV drug users with "simple abscess" may have necrotizing fasciitis (20% mortality); maintain high suspicion and perform subfascial exploration if any doubt 3
- Never attribute post-procedure darkening skin to bruising alone—rule out DVT with urgent Doppler ultrasound 8
- Never perform aggressive fistula probing if no fistula is clinically apparent—this causes iatrogenic sphincter injury 4
- Never prescribe metronidazole monotherapy for skin abscesses—it lacks activity against S. aureus and streptococci 2