What is the recommended management of a small uncomplicated cutaneous abscess in an otherwise healthy adult?

Management of Small Uncomplicated Cutaneous Abscess

Incision and drainage is the definitive treatment for all cutaneous abscesses, and routine antibiotics are not required after adequate drainage in otherwise healthy adults with simple lesions. 1, 2

Primary Treatment: Incision and Drainage

Perform incision and drainage promptly as the cornerstone of therapy for all cutaneous abscesses. 1, 2

Technical Considerations

• Make an adequate incision that allows complete evacuation of purulent material and breaking up of any loculations, as inadequate drainage leads to recurrence rates up to 44%. 2

• Cover the surgical site with dry sterile gauze only—wound packing causes more pain without improving healing and should be avoided for most simple abscesses. 1, 3

• For wounds larger than 5 cm, consider packing to reduce recurrence and complications. 4

• Do not attempt needle aspiration, which has only a 25% success rate overall and less than 10% success with MRSA infections. 1, 5

When Antibiotics Are NOT Needed

Withhold antibiotics after adequate drainage when ALL of the following criteria are met: 1, 2, 3

• Body temperature < 38.5°C 2, 3
• Heart rate < 100 beats/minute 2, 3
• White blood cell count < 12,000 cells/µL 3
• Erythema and induration extending < 5 cm from the wound margin 2, 3
• No immunocompromising conditions 1, 3

Prescribing antibiotics for simple abscesses after adequate drainage contributes to antimicrobial resistance without improving outcomes. 3, 6

When Antibiotics ARE Indicated

Add systemic antibiotics when ANY of the following high-risk features are present: 1, 3, 6

Systemic Signs of Infection (SIRS Criteria)

• Temperature > 38°C or < 36°C 1, 3
• Tachycardia > 90 beats/minute 1, 3
• Tachypnea > 24 breaths/minute 1
• White blood cell count > 12,000 or < 4,000 cells/µL 1, 3

Local Extension or Complexity

• Erythema extending > 5 cm beyond wound margins 2, 3
• Multiple infection sites or rapid progression 3, 6
• Abscess in difficult-to-drain areas (face, hand, genitalia, perirectal) 2, 3

Host Factors

• Immunocompromised status 1, 3, 6
• Diabetes mellitus 2
• Extremes of age 3

Procedural Factors

• Incomplete source control after drainage 2, 3
• Lack of response to incision and drainage alone 3, 6

Antibiotic Selection (When Indicated)

For outpatient empiric coverage of community-acquired MRSA, first-line oral options include: 3, 6

• Clindamycin 300-450 mg PO every 6-8 hours (cure rate 83.1%) 3
• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg (one double-strength tablet) PO twice daily 2, 3
• Doxycycline 100 mg PO twice daily 3
• Linezolid 600 mg PO twice daily (reserved for resistant infections) 2, 3

Duration: 5-10 days based on clinical response. 1, 3

Critical Pitfalls to Avoid

• Do NOT use rifampin as single agent or adjunctive therapy for skin abscesses—it offers no benefit and promotes resistance. 3, 6

• Do NOT use fluoroquinolones for MRSA coverage, as they are inadequate. 6

• Do NOT use ceftriaxone for simple cutaneous abscesses—it lacks activity against MRSA, the predominant pathogen. 6

Culture Recommendations

Routine microbiologic culture is not necessary for typical simple abscesses that have been adequately drained. 3

Obtain cultures when: 1, 3

• Abscesses require percutaneous or surgical drainage
• Suspected bacteremia or sepsis is present
• Treatment failure occurs requiring antibiotic adjustment

Follow-Up

Close follow-up at 48 hours to assess for resolution of erythema, pain, and drainage. 5

Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-evaluation. 2, 3