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Experts release updated recommendations for treatment of skin abscesses
Skin abscesses have become increasingly common, particularly in association with MRSA infection, and despite new therapeutic options, the success rate is highly variable, according to a recent review in The New England Journal of Medicine.
Adam J. Singer, MD, of Stony Brook University in New York, and David A. Talan, MD, of David Geffen School of Medicine at UCLA, outlined updated recommendations for the management of common skin abscesses based on randomized trials as well as clinical experience.
They reviewed drainage of the abscess, irrigation and packing, new surgical approaches and antibiotic treatment.
In particular, Singer and Talan cited studies that reported soft tissue ultrasonography as a highly sensitive means of enhancing abscess detection vs. physical examination alone. They recommended ultrasonography of an abscess before and after fluid drainage and also advised ultrasonography for any large or hardening areas of cellulitis suspected to be an abscess.
The researchers wrote that although the needle aspiration can help confirm an abscess diagnosis, a lack of pus does not necessarily rule out abscess. In addition, needle aspiration may fail to adequately evacuate all fluid from an abscess, and additional drainage may be required.
Singer and Talan said needle aspiration may be used as an initial alternative to incision-based drainage, although they cited research that full drainage and symptom resolution at 7 days is achieved in only 26% of cases vs. an 80% 7-day success rate with incision and drainage. For this reason, clinicians who attain initial success with needle aspiration should caution patients that further drainage may be required.
The investigators also discussed a novel surgical technique known as loop. In this technique, two puncture wounds are created and a small rubber catheter is inserted and guided through the drainage wounds. The two ends of the catheter are tied together, obviating early wound closure. A vertical mattress suture is used for primary wound closure of the drained abscess. Singer and Talan wrote, however, that their experience has indicated that a single small incision is adequate to drain most abscesses. Primary closure was recommended over secondary closure to achieve optimal outcomes.
The researchers discussed the value of packing after incision and drainage and cited a randomized trial that reported packing was related to increased pain, but similar rates of healing and success. They said these findings may have had too few participants to detect clinically significant differences in outcome, but the use of a wick or drain may be substituted for packing in very large abscesses.
According to Singer and Talan, the Infectious Diseases Society of America recommends systemic treatment with antibiotics, besides incision and drainage, only in severe cases, immunosuppressed patients and abscesses recalcitrant to incision and drainage.
“Because of the relatively high failure rates even with optimal treatment, patient education and follow-up are recommended,” the researchers wrote.
Disclosure: Talan is a consultant to and has received institutional grant support from Durata Therapeutics.
Perspective
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Skin and soft tissue infections are among the most common infectious problems leading to ED visits in children, with Staphylococcus aureus being the primary causative agent.
The evolution of community-associated MRSA in the 1990s has led to both an increase in the incidence of skin infection and complicated the antimicrobial management of these infections.
Drs. Singer and Talan provide an excellent overview of the diagnosis and treatment of skin abscesses in the CA-MRSA era. In particular, the authors review the use of ultrasound in diagnosis as well as specific incision and drainage (I&D) techniques, topics that are missing from many reviews on the subject of skin abscesses. Ultrasound, as the authors point out, is a modality that can be helpful in evaluating abscesses when the diagnosis is in question, such as with a very deep-seated purulent collection or extensive overlying cellulitis. Ultrasound has clearly been shown to be a sensitive and valuable modality in adults with skin and soft tissue infections (SSTIs). Studies in children have not been as dramatic as those in adults; however, ultrasound certainly has its place in the diagnostic evaluation of suspected abscesses, and results in management can change.
Even with the increase in CA-MRSA, I&D remains the most important modality for dealing with skin abscesses. The authors provide a very informative overview of I&D procedures, including the potential value in using a two-incision approach with placement of a drain. Notably, such as technique may circumvent the need for wound packing, an often painful procedure. In addition, the authors point out that the prescription of systemic antimicrobials for simple skin abscesses over the trunk or extremities may have limited benefit over I&D alone. Although patients who receive systemic antimicrobials along with drainage may have a lower rate of recurrence of infection, this is an area that requires further investigation.
One of the most common outpatient referrals to pediatric infectious disease specialists is the otherwise healthy child with recurrent skin abscesses, most frequently due to MRSA. The authors provide an overview of the limited literature on the management of such patients, including decolonization regimens. Clearly, colonization increases the risk of subsequent infection and much interest has developed in trying to interrupt this progression. Of particular note for pediatricians, the authors review the study by Fritz and colleagues (Clin Infect Dis. 2012; 54:743-751), which revealed that the use of hygienic education plus a 5-day regimen of intranasal mupirocin and chlorhexidine washes for the entire household was more effective for decreasing recurrent skin infections than decolonization of the index patient alone. The fact that patients continue to have recurrences with significant frequency, regardless of the prevention method used (52% at 12 months in Fritz study), is a frustrating challenge for physicians, patients and their families. Further research is needed to determine the optimal management of these patients.