AOTW: Management of Skin Abscesses
Posted on: September 15, 2014, by : Jaclyn Kline
With the increasing rates of MRSA in the community, questions about how to best treat skin abscesses in the ED have come up. In March 2014, a review article on this topic was published in the New England Journal of Medicine
Diagnosis
The authors cited a large study in Pediatric EDs (349 kids) that showed only ‘fair’ interobserver agreement regarding the presence of an abscess.
Multiple studies looked at ultrasound, in both children and adults, and showed mixed results, but, generally, ultrasound did change management in enough cases to warrant its use, with the caveat of it being done in experienced/capable hands.
Treatment
Incision and drainage is described as the ‘primary’ modality of treatment. Interestingly, they mention two studies in children that looked at simple I&D with packing compared to making two small incisions, draining it and then placing a catheter through the two incisions. This was shown to be comparably effective, and possibly less painful than packing.
They also looked at two small studies in which no packing was done. In the adult study, no difference in healing was found, but in the pediatric study, recurrence at 1 month was greater if no packing was done.
There was one small study (56 adults) that showed that primarily closing the incision after drainage did not significantly affect wound healing outcomes.
Cure rates of community acquired MRSA are near 85% for drainage alone, without antibiotics. Particularly, a study of 161 children showed no significant difference with Bactrim vs. placebo.
The Infectious Diseases Society of America (IDSA) recommends systemic antibiotic treatment, in addition to incision and drainage, for patients with severe or extensive disease (e.g., multiple sites of infection) or with rapid disease progression and associated cellulitis, signs and symptoms of systemic illness, associated coexisting conditions or immunosuppression, very young age or advanced age, an abscess in an area difficult to drain (e.g., face, hands, or genitalia), associated septic phlebitis, or an abscess that does not respond to incision and drainage alone. However, there are no large randomized trials validating these recommendations, clinical trials by NIH are ongoing.
In cases where you cannot distinguish cellulitis vs. early abscess, this article recommends covering for both community acquired MRSA and strep species (so, monotherapy with clindamycin or combination therapy with Bactrim and Keflex), but, again, there are no large randomized trials on this, and it is being investigated by the same NIH clinical trials.
Prevention
One study with 126 children/families completing it showed significant decreased infections if the patient, and entire household perform a 5-day regimen of hygiene, nasal mupirocin treatment, and chlorhexidine body washes. This is only recommended to dedicated families with recurrent infections.
Limitations of this Review
The authors admit in the introduction that they based their guidelines on randomized trials whenever possible, but at times also referenced small, observational studies, or expert opinion.
This study looks at both adult and pediatric data.
This review continues to argue for I&D as the mainstay of treatment. It seems like the jury is out on adults for using packing, but it showed benefit (in one study) in kids, so we need a bigger/better study before not routinely packing after drainage. This review seems to argue against routine antibiotic use (unless there are complicating factors, listed above), and, if follow-up can be assured, antibiotics at time of ED visit do not seem indicated in simple abscesses. Also, if you are packing the wound, you are more likely to get good follow-up, and can re-visit antibiotics at follow up as needed. I would leave the discussion of decolonization to the PCP who can see the kid/family back for multiple follow-ups. Also, we should keep our eyes open for the results of this large clinical trial coming out of NIH looking at abscess/cellulitis management as it may give us more sound data and answers.
Thanks for the review on an important but overlooked topic. The value of ultrasound–but in capable hands–was illustrated in a great post by Lorraine Ng, a PEM ultrasound person at Columbia:
http://www.pemfellows.com/blog/to-drain-or-not-to-drain-that-is-the-question/
As for decolonization, while the body of evidence is not strong, I think there is a role in bringing it up in the ED as some patients may not remember to ask about it when they next see their PMD. Thanks again for the review.