Every so often, it’s good to circle back from the esoteric to the basics, and remind ourselves how to provide the best, evidence-based treatment for some of the most common diseases – in this case, abscesses.
This review in the New England Journal is a reasonable, concise overview of the evidence behind management of cutaneous abscesses, updated for the increasing prevalence of methicillin-resistant Staphylococcus aureus. And, quite simply, there’s no evidence for any reason yet to panic. The authors of this article summarize the literature thusly:
- Incision & drainage is definitive treatment. Non-complicated disease does not require additional antibiotic treatment, and the incremental benefit – if any – would be single-digit differences in clinical failure.
- Packing of abscesses is a matter of tradition, and evidence is neither sufficient to conclusively confirm nor refute this practice.
- Primary closure of abscesses after I&D is reasonable, particularly for larger, exposed, and cosmetically important areas.
- Antibiotic coverage for primarily cellulitic soft-tissue infections ideally includes both MRSA and streptococcal coverage, but recent evidence showed no advantage to double-coverage. Clinical trials regarding antibiotic use are ongoing: NCT00729937 NCT00730028 NCT00729937
- Wound cultures are not necessary.
One could argue covering such basics in infection and wound management is a sundry affair for a blog frequently covering the cutting edge. However, current management of such a common condition is so highly variable and frequently low-value, ACEP even made a point to include abscess management in their Choosing Wisely campaign list.
Now, go and do as little harm as possible.
“Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus”
http://www.ncbi.nlm.nih.gov/pubmed/24620867