Abscess

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An abscess is defined as an "accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection."[1] The most basic step in treatment, therefore, is to release excess purulent material, the pressure of which may be causing additional tissue destruction as well as occluding blood flow to the area.

Pathogens

Some absecceses are caused by methicillin-resistant Staphylococcus aureus (MRSA). According to a clinical prediction rule, these are more likely to be "small, irregularly shaped, or indistinct, with ill-defined edges."[2]

Treatment of skin abscesses

Clinical practice guidelines for treatment are available.[3]

Aspiration

Ultrasonographically guided needle aspiration is not sufficient.[4]

Incision and drainage

The abscess should be treated with incision and drainage.[5]

In some cases, it may be possible to evacuate purulent material with a needle and syringe, possibly irrigating the abscess. In other cases, based on clinical judgment, warm wet compresses may cause the abscess to open and release the material under pressure. It still may be necessary to irrigate and debride an abscess that has spontaneously unroofed.

[{Anesthesia]] for incision and drainage can be challenging. Especially when the abscess is near the skin surface and not on an extremity, there may be no practical way to use local anesthesia because the infected area cannot be infiltrated with an anesthetic. The risks of general anesthesia, however, may not be warranted for the severity of the abscess. While the initial incision may be painful, the release of fluid under pressure can give immediate pain relief. Opioid analgesics before the procedure may be a reasonable compromise, or possibly conscious sedation.

Topical antibiotics are controversial. Silver sulfadiazine is often used.

Packing

Although packing of the abscess cavity is commonly done after drainage, it may delay healing[6][7], increase discomfort[8], and not reduce repeat procedures at 48 hours[8].

Primary closure

This topic has been studied by systematic review.[9]

Randomized controlled trials of primary closure of non-anorectal skin abscesses.[5] [10] [11] [12] [13]
Trial Patients Intervention Comparison Outcome Results Comment
Intervention Control
Mcfie[5]
1977
219 patients Primary closure (factorial design with/without antibiotics)         No differences among four study groups
Simms[10]
1982
114 patients Primary closure   Various outcomes     Primary closure delayed healing by one day
Stewart[11]
1985
137 patients
• All abscesses were drained, curetted, and irrigated
Primary closure   Various outcomes     Primary closure significantly better
Abraham[12]
1997
61 patients
• "Abscesses requiring drainage under a general anaesthetic"
• All abscesses were drained, curetted, and irrigated
Primary closure with interrupted vertical mattress skin sutures with/without closed suction drainage Packing • Healing at one week
• Healing at one month
    Primary closure significantly better at one week; no difference at one month.
Singer[13]
2013
56 patients Primary closure with vertical mattress sutures Packing Failure to health at one week 30% 29% Primary closure significantly better
               

In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary healing and recurrence was higher.[14]

Antibiotics

A clinical practice guideline by the Infectious Disease Society of America concludes that "Gram stain, culture, and systemic antibiotics are rarely necessary"[3]; however, according the National Guideline Clearinghouse summary of this guideline, the guideline was not a systematic review of the evidence.[15]

Antibiotics should be considered if there is significant overlying cellulitis. Systematic reviews of relevant studies concluded that:[16][17]

"the current literature does not support the routine practice of prescribing antibiotics after incision and drainage of simple cutaneous abscesses, even in high-MRSA-prevalence areas"
"our conclusions cannot be extrapolated to those cases in which there is a significant degree of overlying cellulitis"

Randomized controlled trials

There are conflicting randomized controlled trials to guide the decision for antibiotics.[18][5][19][20][21][22] Some trials are undersized.[21]The strongest support for using antibiotics is from a trial of clindamycin.[5] and a trial of trimethoprim-sulfamethoxazole[22]. The strongest refutations of antibiotics were a trial of cephradine[18] and maybe an older trial of penicillin[20]. In the most recent trial, although 87.8% of isolates were methicillin-resistant staphylococcus aureus (MRSA), the antibiotic used was cephalexin which is inactive against MRSA. It is not known if an antibiotic effective against MRSA would have reducted the rate of treatment failures below the 10% failure rate observed in the trial.[23] However, the clindamycin trial above[5] and one cohort study below[24] suggests effective antibiotic therapy helps.

Additional trials exit, however, one did not have a placebo group.[25] A pediatric trial found short term benefit from trimethoprim-sulfamethoxazole after incision and drainage.[26]

No trial has separately reported the role of antibiotics for large abscesses (> 5 cm). Large abscesses may be less likely to respond without antibiotics.[27]

Observational cohort studies

Observational cohort studies of patients with MRSA produce conflicting results with one study supporting antibiotics[24], other studies not supporting[28][29][27] although one[27] of three three nonsupporting studies actually reported an insignificant tendency towards improvement with antibiotics.

In the supporting cohort study, active antibiotics improved the cure rate from 87% to 95% among 492 patients with community-onset MSRA.[24] 80% of patients received incision and drainage. About a third of the patients were hospitalized.

Among the three cohort studies refuting antibiotics, the strongest study found that among 196 patients who received incision and drainage, 11% of those receiving active antibiotics required a repeat procedure whereas only 7% of those receiving inactive antibiotics.[29] Similar results occurred in the 257 patients who did not receive incision and drainage. About a third of the patients were hospitalized.

Among the other refuting studies, one that claimed antibiotics do not work found actually found a statistically insignificant trend towards improvement with all five (100%) of children treated with active antibiotics improved as compared to 58 of 62 (94%) treated with inactive antiobiotics.[27] The other nonsupporting study found there was "no significant differences" (rates not provided by the article) among patients treated with active antibiotics versus those treated with inactive antibiotics.[28]

In a cohort analysis of a randomized controlled trial that compared cefdinir vs. cephalexin, neither of which is effective at MRSA, found that the rate of clinical cure was 92% (66/72) for patients infected by MRSA versus 91% (72/79) for patient infected by MSSA.[30] However, only 26% of these patients had abscesses.

A study of failed treatment, although half of these patients had a cutaneous cellulitis, concluded that failure is reduced if:[31]

Prevention

To prevent recurrent infections due to Staphylococcus aureus, consider the following measures:

  • Topical mupirocin applied to the nares.[32] In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.[33] The does is about 1 centimeter of ointment on a swab applied to each nares.[34]
  • Chlorhexidine baths,[35] in a randomized controlled trial, nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach statistical significance, the baths are easy to do.

References

  1. National Library of Medicine. Abscess. Retrieved on 2007-10-19.
  2. Gaspari RJ, Blehar D, Polan D, Montoya A, Alsulaibikh A, Liteplo A (2014). "The Massachusetts abscess rule: a clinical decision rule using ultrasound to identify methicillin-resistant Staphylococcus aureus in skin abscesses.". Acad Emerg Med 21 (5): 558-67. DOI:10.1111/acem.12379. PMID 24842508. Research Blogging.
  3. 3.0 3.1 Stevens DL, Bisno AL, Chambers HF, et al. (November 2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clin. Infect. Dis. 41 (10): 1373–406. DOI:10.1086/497143. PMID 16231249. Research Blogging.
  4. Gaspari RJ, Resop D, Mendoza M, Kang T, Blehar D (2011). "A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus.". Ann Emerg Med 57 (5): 483-91.e1. DOI:10.1016/j.annemergmed.2010.11.021. PMID 21239082. Research Blogging.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Macfie J, Harvey J (1977). "The treatment of acute superficial abscesses: a prospective clinical trial". The British journal of surgery 64 (4): 264-6. PMID 322789[e] Among patient receiving incision and drainage, clindamycin 150 mg every 6 hours improved cure rate from 94% to 100%. However, results were statistically insignificant due to small size
  6. 1: Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7. doi: 10.1097/PEC.0b013e3182587b20. PMID: 22653459
  7. BestBets: abscesses; to pack or not to pack.
  8. 8.0 8.1 O'Malley GF, Dominici P, Giraldo P, et al. (April 2009). "Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary". Acad Emerg Med. DOI:10.1111/j.1553-2712.2009.00409.x. PMID 19388915. Research Blogging.
  9. Singer AJ, Thode HC, Chale S, Taira BR, Lee C (2011). "Primary closure of cutaneous abscesses: a systematic review.". Am J Emerg Med 29 (4): 361-6. DOI:10.1016/j.ajem.2009.10.004. PMID 20825801. Research Blogging.
  10. 10.0 10.1 Simms MH, Curran F, Johnson RA, et al (1982). "Treatment of acute abscesses in the casualty department". British medical journal (Clinical research ed.) 284 (6332): 1827-9. PMID 6805714[e]
  11. 11.0 11.1 Stewart MP, Laing MR, Krukowski ZH (1985). "Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial". The British journal of surgery 72 (1): 66-7. PMID 3881155[e]
  12. 12.0 12.1 Abraham N, Doudle M, Carson P (1997). "Open versus closed surgical treatment of abscesses: a controlled clinical trial". The Australian and New Zealand journal of surgery 67 (4): 173-6. PMID 9137156[e]
  13. 13.0 13.1 Singer et al. (2013)Primary Versus Secondary Closure of Cutaneous Abscesses in the Emergency Department: A Randomized Controlled Trial. Acad Emerg MedDOI:10.1111/acem.12053
  14. Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up". Acta Chirurgica Scandinavica 150 (8): 689-92. PMID 6397949[e]
  15. Anonymous (2005). Practice guidelines for the diagnosis and management of skin and soft-tissue infections.. National Guidelines Clearinghouse.
  16. Hankin A, Everett WW (2007). "Are antibiotics necessary after incision and drainage of a cutaneous abscess?". Annals of emergency medicine 50 (1): 49-51. DOI:10.1016/j.annemergmed.2007.01.018. PMID 17577944. Research Blogging. PMID 17577944
  17. Korownyk C, Allan GM (2007). "Evidence-based approach to abscess management". Canadian family physician Médecin de famille canadien 53 (10): 1680–4. PMID 17934031[e]
  18. 18.0 18.1 Llera JL, Levy RC (1985). "Treatment of cutaneous abscess: a double-blind clinical study". Annals of Emergency Medicine 14 (1): 15–9. DOI:10.1016/S0196-0644(85)80727-7. PMID 3880635. Research Blogging. “Ninety-six percent of the patients in each group were improved clinically after seven days”
  19. Rutherford WH, Hart D, Calderwood JW, Merrett JD (May 1970). "Antibiotics in surgical treatment of septic lesions". Lancet 1 (7656): 1077–80. PMID 4191960[e] Patients randomized to receive cloxacillin has an insignificant trend to improve one half day faster
  20. 20.0 20.1 Anderson J (December 1958). "Dispensability of post-operative penicillin in septic-hand surgery". Br Med J 2 (5112): 1569–71. PMID 13608051. PMC 2028058. “17% were penicillin-resistant...Routine post-operative penicillin does not hasten healing in septic lesions of the hand which require surgical treatment” [e] However, this was an insignificant trend towards more complications in the group without antibiotics
  21. 21.0 21.1 Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J et al. (2010). "Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection.". Ann Emerg Med 56 (3): 283-7. DOI:10.1016/j.annemergmed.2010.03.002. PMID 20346539. Research Blogging. 17% failure with TMP/SMX versus 26 failure in placebo. However, not significant - perhaps due to size of the study.
  22. 22.0 22.1 Holmes L, Ma C, Qiao H, Drabik C, Hurley C, Jones D et al. (2015). "Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in Methicillin-Resistant Staphylococcus aureus Skin Abscesses after Surgical Drainage.". J Pediatr. DOI:10.1016/j.jpeds.2015.10.044. PMID 26578074. Research Blogging.
  23. Rajendran PM, Young D, Maurer T, et al (2007). "Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection". Antimicrob. Agents Chemother. 51 (11): 4044–8. DOI:10.1128/AAC.00377-07. PMID 17846141. Research Blogging.
  24. 24.0 24.1 24.2 Ruhe JJ, Smith N, Bradsher RW, Menon A (March 2007). "Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome". Clin. Infect. Dis. 44 (6): 777–84. DOI:10.1086/511872. PMID 17304447. Research Blogging.
  25. Burn JI, Curwen MP, Huntsman RG, Shooter RA (July 1957). "A trial of penicillin V; response of penicillin-resistant staphylococcal infections to penicillin". Br Med J 2 (5038): 193–6. PMID 13446439. PMC 1961881. “patients were treated in alternate periods of six weeks by injection or penicillin V by mouth...therefore no control group...25% were infected with penicillin resistant strains of Staph. pyogenes” [e]
  26. Duong M, Markwell S, Peter J, Barenkamp S (April 2009). "Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient". Ann Emerg Med. DOI:10.1016/j.annemergmed.2009.03.014. PMID 19409657. Research Blogging.
  27. 27.0 27.1 27.2 27.3 Lee MC, Rios AM, Aten MF, et al (February 2004). "Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus". Pediatr. Infect. Dis. J. 23 (2): 123–7. DOI:10.1097/01.inf.0000109288.06912.21. PMID 14872177. Research Blogging.
  28. 28.0 28.1 Moran GJ, Krishnadasan A, Gorwitz RJ, et al (August 2006). "Methicillin-resistant S. aureus infections among patients in the emergency department". N. Engl. J. Med. 355 (7): 666–74. DOI:10.1056/NEJMoa055356. PMID 16914702. Research Blogging.
  29. 29.0 29.1 Fridkin SK, Hageman JC, Morrison M, et al (April 2005). "Methicillin-resistant Staphylococcus aureus disease in three communities". N. Engl. J. Med. 352 (14): 1436–44. DOI:10.1056/NEJMoa043252. PMID 15814879. Research Blogging.
  30. Giordano PA, Elston D, Akinlade BK, et al (December 2006). "Cefdinir vs. cephalexin for mild to moderate uncomplicated skin and skin structure infections in adolescents and adults". Curr Med Res Opin 22 (12): 2419–28. DOI:10.1185/030079906X148355. PMID 17257456. Research Blogging.
  31. Halilovic J, Heintz BH, Brown J (2012). "Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess.". J Infect. DOI:10.1016/j.jinf.2012.03.013. PMID 22445732. Research Blogging.
  32. van Rijen M, Bonten M, Wenzel R, Kluytmans J (2008). "Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers". Cochrane Database Syst Rev (4): CD006216. DOI:10.1002/14651858.CD006216.pub2. PMID 18843708. Research Blogging.
  33. Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y (1996). "A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection.". Arch Intern Med 156 (10): 1109-12. PMID 8638999.
  34. Harbarth S, Dharan S, Liassine N, Herrault P, Auckenthaler R, Pittet D (June 1999). "Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus". Antimicrob. Agents Chemother. 43 (6): 1412–6. PMID 10348762. PMC 89288[e]
  35. Watanakunakorn C, Axelson C, Bota B, Stahl C (1995). "Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents.". Am J Infect Control 23 (5): 306-9. PMID 8585642.