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Incidence and Recurrence of Boils and Abscesses Within the First Year: a Cohort Study in UK Primary Care

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Incidence and Recurrence of Boils and Abscesses Within the First Year: a Cohort Study in UK Primary Care Research Laura J Shallcross, Andrew C Hayward, Anne M Johnson and Irene Petersen Incidence and recurrence of boils and abscesses within the first year: a cohort study in UK primary care Abstract INTRODUCTION study was to determine the burden of Background Skin conditions are a major cause of recurrent disease and identify opportunities Boils and abscesses are common in primary consultations in primary care with for secondary prevention in these patients. care but the burden of recurrent infection is approximately 2.4 million consultations per unknown. year in England and Wales.1 In 2010, based MeThOD Aim on an estimated UK population of 62 million, The THIN database is a source of To investigate the incidence of and risk factors for recurrence of boil or abscess for individuals there were at least 280 000 primary care anonymised clinical information about 2 16 consulting primary care. consultations for an abscess or boil. 11 million patients in primary care. In the The epidemiology of boils and abscesses UK, 98% of the population is registered Design and setting Cohort study using electronic health records in primary care is poorly understood. with a GP who provides advice, treatment, from primary care in the UK. Suppurative skin infections such as sycosis prescriptions, and referrals and acts barbae,3 impetigo,4 and furunculosis5 as a gatekeeper to specialist services.17 Method The Health Improvement Network (THIN) are more common in patients who are Practices that participate in the THIN database was used to identify patients who colonised with Staphylococcus aureus and scheme of data collection enter information had consulted their GP for a boil or abscess. there is evidence that boils and abscesses on symptoms, diagnoses, treatments, Poisson regression was used to examine the are associated with social deprivation, laboratory investigations, and referrals relationship between age, sex, social deprivation, and consultation and to calculate the incidence overcrowding, the use of communal every time a consultation takes place, using of, and risk factors for, repeat consultation for a facilities, obesity, diabetes, and impaired a hierarchical system of more than 103 000 boil or abscess. immunity.6–9 Patients consulting primary Read Codes.18 Prescriptions are recorded Results care with a boil or abscess will be treated using MULTILEx drug codes that link each Overall, 164 461 individuals were identified either with antibiotics or with surgical formulation of each drug to the British who consulted their GP for a boil or abscess incision and drainage,10 but treatment National Formulary. Each patient in the between 1995 and 2010. The incidence of first consultation for a boil or abscess was 512 options for those with recurrent boils is database is allocated a Townsend score (95% CI = 509 to 515) per 100 000 person- limited beyond addressing any underlying linked to their postcode (which is a composite years in females and 387 (95% CI= 385 to immune disorders and screening for measure of social deprivation based on 390) per 100 000 person-years in males. First diabetes.11 Patients can be tested for levels of house ownership, overcrowding, consultations were most frequent in younger age groups (16–34 years) and those with the staphylococcal carriage and decolonised; car ownership, and unemployment). The greatest levels of social deprivation. The rate of in the UK this may include screening for practices are broadly representative of UK repeat consultation for a new infection during the Panton-Valentine leukocidin toxin practices in terms of the age and sex of follow up was 107.5 (95% confidence interval 12,13 [CI] = 105.6 to 109.4) per 1000 person-years. (PVL). However, the effectiveness of such patients, the practice size and geographical Obesity (relative risk [RR] 1.3, 95% CI= 1.2 interventions is questionable and they are location.19 Adequacy of death recording is to 1.3), diabetes (RR 1.3, 95% CI = 1.2 to 1.3), resource intensive.14,15 assessed by determining the date at which smoking (RR 1.3, 95% CI = 1.2 to 1.4), age There is a clear need for guidance on the practice recorded mortality rates that <30 years (RR 1.2, 95% CI = 1.2 to 1.3), and prior antibiotic use (RR 1.4, 95% CI = 1.3–1.4) were all how to manage patients with recurrent were comparable to national age and sex associated with repeat consultation for a boil or disease in the community. The aim of this standardised mortality rates (AMR date).20 abscess. Conclusion L J Shallcross, PhD, clinical lecturer in public College London, Farr Institute of Health Ten percent of patients with a boil or abscess health; AC Hayward, MD, professor of infectious Informatics Research, 222 Euston Road, London develop a repeat boil or abscess within disease epidemiology; AM Johnson, MD, professor NW1 2DA. 12 months. Obesity, diabetes, young age, of infectious disease epidemiology, Research e-mail: [email protected] smoking, and prescription of an antibiotic Department of Infection and Population Health; Submitted: 12 January 2015; editor’s response: in the 6 months before initial presentation I Petersen, PhD, reader in epidemiology and were independently associated with recurrent statistics, Research Department of Primary Care 13 April 2015; final acceptance: 30 April 2015. infection, and may represent options for and Population Health, University College London, ©British Journal of General Practice prevention. London. This is the full-length article (published online Address for correspondence 28 Sep 2015) of an abridged version published Keywords in print. Cite this article as: Br J Gen Pract 2015; abscess; boils; epidemiology; primary care; risk Laura J Shallcross, Research Department of factors. Infection and Population Health, University DOI: 10.3399/bjgp15X686929 e668 British Journal of General Practice, October 2015 described by Davé et al.22 Finally, individuals how this fits in diagnosed with hidradenitis suppurativa Boils and abscesses are a common were identified. To identify patients with condition in primary care but there is type 1 or type 2 diabetes a combination of little information on the burden of and the medical, prescription, and additional risk factors for recurrent disease. In this health data records was used. Patients study 10% of patients consulting for a with any record corresponding to diabetes boil or abscess developed a second boil were classified as diabetic, even if diagnosis or abscess during the following year. was after the date of first consultation for Consultations for boils and abscesses a boil or abscess, on the assumption that are most common in young, socially- deprived females and are associated with these patients were diabetic at the time of smoking, diabetes, obesity, and recent infection. antibiotic use in the prior 6 months. Weight Therapy records were used to identify loss, smoking cessation, and reducing patients prescribed oral corticosteroids or unnecessary antibiotic use could represent antibiotics in the 6 months prior to the date strategies for secondary prevention. of index consultation. The British National Formulary was used for classification. Antibiotic prescriptions in the 30 days Patients were eligible for inclusion in before first consultation for a boil or abscess the study if they were registered with a were disregarded in case they represented participating practice that met acceptable treatment without a corresponding medical mortality recording (AMR) standards and record for a boil or abscess. was fully computerised between 1 January Antibiotic treatment at baseline was 1995 and 31 December 2011.21 Individuals defined as prescription of any antibiotic were identified if they sought care for a within 2 weeks of the date of the first boil, abscess, carbuncle, or furuncle, consultation for a boil or abscess. identified by a Read Code list (Appendix 1). To define smoking status the record Patients were excluded from the cohort if closest to the date of consultation for a boil they were registered with a participating or abscess was used in the context of the practice for <6 months before the date patients’ longitudinal record. Body mass of first consultation (with the exception index was defined using the record in the of infants aged <1 year), or if they had additional health data file that was closest <1 year of follow-up data from that date. to the date of consultation for a boil or For the multivariate analysis patients with abscess. a diagnosis of hidradenitis suppurativa (a First, Poisson regression was used to condition characterised by repeat boils) investigate the relationship between initial were excluded as these individuals were consultations for a boil or abscess, age, thought to represent a distinct patient group. sex, and social deprivation. Subsequently, a Patients entered the cohort on the date of cohort was selected from the full dataset to their first consultation for a boil or abscess study factors associated with recurrent boil and exited on the first of the following dates: or abscess. The baseline characteristics the date of second (repeat) consultation for of this cohort were summarised using a boil or abscess; the date of death; the date descriptive statistics. For variables where the patient left the practice; or 31 December >5% of patients lacked a record (for body 2011. mass index [BMI] and smoking status), Outcome was defined as any consultation patients with missing data were compared that resulted in a record of a boil or abscess to those with a complete case record. occurring between 3 weeks and 12 months Provided those with a missing record were after the date of first consultation for an not systematically different from those with abscess or boil. Recurrent boil or abscess a complete record, missing records were was defined as a second consultation for a reclassified as within the normal range boil or abscess that occurred a minimum of on the assumption that this was why they 21 days after the previous consultation.
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