Systemic Antibiotics After Incision and Drainage of Simple Abscesses: a Meta-Analysis

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SYSTEMIC ANTIBIOTICS AFTER INCISION AND DRAINAGE OF SIMPLE ABSCESSES: A META-ANALYSIS

Singer, A.J., et al, Emerg Med J 31(7):576, July 2014

BACKGROUND: The number of ED visits for treatment of an abscess increased by nearly three-fold between 1996 and 2005, surpassing the overall increase in total ED visits during that period. Antibiotics are prescribed for about half of patients treated for abscess in the ED, but small observational studies of the effects this intervention have yielded inconclusive results.

METHODS: The authors, from Stony Brook (NY) University, performed a meta-analysis of four randomized, controlled trials comparing outcomes in 428 adults and 161 children undergoing incision and drainage of an uncomplicated cutaneous abscess in the ED who were assigned to adjunctive antibiotics (cephradine, cephalexin or trimethoprim-sulfamethoxazole) or placebo.

RESULTS: There was no difference between the study groups in complete resolution at seven to ten days (88.1% in active treatment groups vs. 86.0% of placebo-treated controls, odds ratio [OR] 1.17, 95% CI 0.70-1.95) or in rate of recurrence at 30-90 days (evaluated in two trials) (81.5% in the antibiotic treatment groups vs. 71.6% in controls, OR 1.74, 95% CI 0.88-3.45).

CONCLUSIONS: The use of adjunctive antibiotics after I&D of an uncomplicated cutaneous abscess does not appear to improve early cure or recurrence rates. Recent guidelines of the Infectious Diseases Society of America targeting treatment of MRSA infections in adults and children recommend reserving systemic antibiotics after I&D for patients with severe or extensive involvement, rapid progression in conjunction with associated cellulitis, evidence of systemic illness or septic phlebitis, comorbidity or immunosuppression, extreme age, abscess location in an area that is difficult to drain, and/or a lack of response to incision and drainage. 15 references ( – no reprints)

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INCISION AND DRAINAGE OF SUBCUTANEOUS ABSCESSES WITHOUT THE USE OF PACKING

Leinwand, M., et al, J Ped Surg 43:1962, 2013

BACKGROUND Wound packing is often routinely performed after incision and drainage (I&D) of subcutaneous abscesses. Removal of the packing can be quite painful and distressing to children. It is uncertain if routine packing improves patient outcomes.

METHODS: In this prospective study, from Bronson Children’s Hospital in Kalamazooo, MI, 100 immunocompetent nondiabetic children undergoing I&D of subcutaneous abscesses were randomized to packing or no packing of the wound after the procedure and followed at 7 and 30 days after the procedure. The study excluded patients with diabetes, perianal or pilonidal abscesses, those secondary to a previous operative procedure, hidradenitis, or an infected subcutaneous cyst. Packing was performed with dry 0.5-inch Nu Gauze Plain Packing Strip and was removed by a caregiver after 24 hours. All of the children were treated with a seven-day course of trimethoprim-sulfamethoxazole. Additional management in both groups include twice daily warm soaks, and covering of the wound with plain gauze or a clean diaper.

RESULTS: The study was completed by 85 patients. Wound cultures were positive for methicillin-resistant S. aureus in 81% of the packing group and 86% of the comparison group. There were no differences between the groups in patient age or gender, or in abscess diameter or location. Abscess recurrence developed in one patient in each group (about 2% each).

CONCLUSIONS: Wound packing had no apparent beneficial effect in immunocompetent children undergoing incision and drainage of subcutaneous abscesses. 13 references ( – no reprints)

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PRIMARY VERSUS SECONDARY CLOSURE OF CUTANEOUS ABSCESSES IN THE EMERGENCY DEPARTMENT: A RANDOMIZED CONTROLLED TRIAL

Singer, A.J., et al, Acad Emerg Med 20(1):27, January 2013

BACKGROUND: Some studies performed outside of the ED setting have reported more rapid healing of cutaneous abscesses that are managed with primary closure after incision and drainage (I&D) rather than those that are left open.

METHODS: In this study, from Stony Brook (NY) University, 56 healthy patients presenting to an urban or suburban ED with a localized cutaneous abscess requiring I&D in the absence of significant surrounding cellulitis were randomized to primary closure with 4-0 monofilament vertical mattress sutures or to loose packing and healing by secondary intention. I&D was performed via a stab incision. Packing was removed at the two-day follow-up. Sutures were removed and loose packing instituted if there was concern about significant reaccumulation of pus among patients initially randomized to suture closure. Final follow-up was performed at seven days.

RESULTS: The mean patient age was 37 years and the median abscess size was 5cm2 (range 1-150cm). Abscesses involved the head and neck, axilla, extremities, trunk or buttocks. At the two-day follow-up, additional drainage was required in six of 27 patients randomized to primary closure and four of 28 randomized to secondary closure. There were no statistical differences in the rate of abscess reformation at seven days (1/23 and 4/28 in the primary and secondary closure groups), or the rate of complete healing at seven days (16/23 and 16/27, respectively). On a scale of 0-10, median patient satisfaction scores were 9 and 10 in the two groups, respectively.

CONCLUSIONS: In this small study, outcomes were similar in patients presenting to the ED with a cutaneous abscess who were managed with primary or secondary closure after I&D. 20 references ( for reprints)

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RANDOMIZED TRIAL COMPARING WOUND PACKING TO NO WOUND PACKING FOLLOWING INCISION AND DRAINAGE OF SUPERFICIAL SKIN ABSCESSES IN THE PEDIATRIC EMERGENCY DEPARTMENT

Kessler, D.O., et al, Ped Emerg Care 28(6):514, June 2012

BACKGROUND: Wound packing is often performed after incision and drainage (I&D) of an abscess, but the evidence supporting this practice is limited, at best.

METHODS: In this prospective, single-blind study, from Columbia University, 49 immunocompetent patients aged 1-24 years undergoing I&D of a superficial skin or soft tissue abscess in the pediatric ED were randomized to wound packing with quarter-inch non-iodoform gauze ribbon after the procedure or to no packing. Abscesses less than 1cm in diameter or involving the face, genitals or perianal area were excluded.

RESULTS: On ultrasound assessment, the mean abscess volume was 3.6ml in the packing group and 4.2ml in the no packing group. Culture was positive for MRSA in about one-third of the abscesses in each group. Additional interventions (repeat I&D or exploration, antibiotics, packing or a repeat visit) were performed on follow-up at 48 hours in most patients (19/27 of the packing group and 13/22 of the no packing group). There were no statistical differences between the groups in pain scores after the procedure or at 48 hours, in the percentage of patients exhibiting healing at one week (about one-third), or in the frequency of recurrence at one month (2/22 patients in the no packing group and 0/27 in the packing group). More than 90% of patients in both groups expressed satisfaction with the scar appearance at one month.

CONCLUSIONS: Findings in this small study suggest that wound packing after I&D of a superficial skin/soft tissue abscess in the pediatric ED does not improve patient outcomes and may be unnecessary. 15 references ( for reprints)

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PRIMARY CLOSURE OF CUTANEOUS ABSCESSES: A SYSTEMATIC REVIEW

Singer, A.J., et al, Am J Emerg Med 29(4):361, May 2011

BACKGROUND: The traditional approach to the management of a cutaneous abscess consists of incision and drainage (I&D) followed by secondary healing via granulation and reepithelialization. Several studies have reported that primary closure after I&D might be associated with greater improvement in selected outcomes.

METHODS: The authors, from Stony Brook (NY) University, performed a meta-analysis of seven randomized controlled trials (915 patients in four countries, between 1976-2001) comparing primary and secondary closure after I&D of a cutaneous abscess.

RESULTS:. Six of the seven studies were published prior to 2000, before the pronounced increase in community-associated methicillin-resistant S. aureus (CA-MRSA). More than half of the abscesses involved the anogenital region. The mean healing time was 7.8 days with primary suture closure vs. 15.0 days with secondary closure, and the mean times to return to work were 4.1 vs. 14.6 days, respectively. The mean complication rate was 8.1% in patients randomized to primary suture closure vs. 11.0% in those randomized to secondary closure, and mean rates of abscess recurrence were 7.6% vs. 11.1%, respectively. One study that assessed appearance of the wound after three months reported a "good" quality scar in 90% of patients randomized to primary suture closure vs. 29% of those randomized to secondary closure.

CONCLUSIONS: In these patients, primary suture closure after I&D of a cutaneous abscess was associated with more rapid healing and a lower rate of abscess recurrence than was secondary closure. However, these study subjects do not seem to be representative of most current ED patients, so the findings should be interpreted with caution. 23 references ( - no reprints)

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RANDOMIZED, CONTROLLED TRIAL OF ANTIBIOTICS IN THE MANAGEMENT OF COMMUNITY-ACQUIRED SKIN ABSCESSES IN THE PEDIATRIC PATIENT

Duong, M., et al, Ann Emerg Med 55(5):401, May 2010

BACKGROUND: There is some debate as to whether antibiotics are required following adequate incision and drainage of a skin abscess caused by community-acquired methicillin-resistant S. aureus (CA-MRSA).

METHODS: In this controlled clinical trial, from St. Louis (MO) University, 149 evaluable children aged 3 months to 18 years (median, 4 years) presenting to a pediatric ED with a skin abscess were randomized, after incision and drainage, to a ten-day course of trimethoprim-sulfamethoxazole (10-12mg/kg/day of trimethoprim in two divided doses [maximum 160mg/dose]) or placebo.

RESULTS: There were no differences between the groups in baseline characteristics. About half the children (53%) were below the age of five years and the abscess was most often located in the diaper region. No adverse effect was reported for 81% of the antibiotic group and 88% of controls, and there were no serious adverse effects. CA-MRSA was isolated in 80% of the lesions (clindamycin resistance 18%, 100% sensitivity to TMP-SMX). The treatment failure rate at ten days (any erythema, warmth, induration, fluctuance, tenderness and/or drainage) was not different (4.1% in the TMP-SMX group and 5.3% in controls). Development of a new lesion at 10 days occurred more frequently in controls (26%, vs. 13% of the antibiotic group), but by three months a new lesion had developed in 29% and 28%, respectively.

CONCLUSIONS: The authors suggest that antibiotic treatment does not appear to be necessary after I&D for children presenting with a skin abscess, although antibiotic therapy did tend to reduce the development of new lesions in the short term. 14 references ( for reprints)

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