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Abscess Management I Just Wanted to Send out a Little Educational Module on Abscess Management. We See Many Abscesses in the Em

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Abscess Management I Just Wanted to Send out a Little Educational Module on Abscess Management. We See Many Abscesses in the Em Abscess Management I just wanted to send out a little educational module on abscess management. We see many abscesses in the emergency department - the majority of which are MRSA. I will cover a few education points, including 1. First and foremost, the definitive treatment for an abscess’s is incision and drainage. 2. Traditionally, all abscesses were packed. However, a few years back, a study indicated that it might not be necessary to pack uncomplicated abscesses. 3. Bactrim (or doxy) is beneficial for MRSA abscesses that are I&D’ed. 4. Which abscesses should be cultured? (Hint – Very Few) Incision and drainage have always been the mainstay of abscess management. The reason antibiotics do not work as there’s no blood supply to an abscess, and thus, it will never get better until the pus is expressed. There are some cases where it may be difficult to tell if there is an abscess or not; however if there’s any question, the easiest way to determine if there is a pus pocket is by inserting a needle and aspirating. If pus returns, the wound needs to be opened and drained. Do Abscesses require packing? Let’s consider the simplest form of an abscess – a pimple. Millions of pimples are popped every day and do not require packing—the simple removal of the pus and allowing it to drain fixes the problem. For simple, uncomplicated abscesses, and incision and drainage with the removal of the pus may be all that’s necessary.1 The problem is that MRSA is a very purulent organism, and having a wick or simple packing will allow the continued drainage of pus. The concern is that the skin will close in the abscess will reaccumulate if it is not packed. Personally, for abscesses with any loculations that have to be broken up with a hemostat, I always put a small amount of packing in the wound. You do not have to put 10 yards of packing. Just enough so that the wound can drain. I tell the patient with simple abscess packing to pull the drain out in the shower after two days of Bactrim. Let’s look at the study that concluded abscesses did not need to be packed.1 They excluded many commonly encountered abscesses we treat and discharge from the ER every day. ”This study excluded abscesses larger than 5cm, pregnancy, co-morbid medical conditions including diabetes, HIV or any malignancy, chronic steroid use, immunosuppressive states including but not limited to sickle cell disease and sarcoidosis, abscess located on the face, neck, scalp, hands, feet perianal, rectal or genital areas, hidradenitis or pilonidal abscesses and need for procedural sedation or supplemental treatment (IV antibiotics or surgical consult to drain). “ What’s the correct answer for packing? I think for very simple abscesses, they can be left open to drain after I&D and treated with Bactrim. However, anything that requires you to break up loculations is probably better served by placing a small packing in the wound. Are antibiotics necessary after drainage of an abscess? There have been several studies that have shown that this is beneficial.2 Since the majority of abscesses are MRSA. The answer is yes. If you suspect surrounding cellulitis, you need to provide additional coverage for streptococcal infections (Bactrim does NOT cover streptococcal infections), cephalexin, or clindamycin if penicillin-allergic.2 Which abscesses should be cultured? The majority of abscesses do not require a culture. However, if the patient requires hospitalization, or has failed treatment with antibiotics, or is a diabetic, or is immunocompromised, the culture should be obtained. Since 95% of abscesses we drain are discharged, the vast majority do not need cultures. What motivated me to write this? Almost all of my shifts last month were in ER South. I saw some abscess bounce backs that were unsuccessfully treated with antibiotics only, or they were drained but not packed and the abscess reaccumulated. 1. O'Malley, G.F., et al., Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2009. 16(5): p. 470-3. 2. Singer, A.J. and D.A. Talan, Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. The New England journal of medicine, 2014. 370(11): p. 1039-47. .
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