Treatment of Abscess with Purulent Drainage

Primary Treatment Approach

The primary and definitive treatment for a cutaneous abscess with purulent drainage is incision and drainage, with antibiotics reserved for specific high-risk conditions, as recommended by the Infectious Diseases Society of America 1, 2
Incision and drainage is the cornerstone of treatment for all abscesses with purulent drainage, and for simple, uncomplicated abscesses in otherwise healthy patients, I&D alone is sufficient without antibiotics 1, 2

The incision should be placed as close as possible to the anal verge or at the point of maximal fluctuance to minimize potential fistula length while ensuring complete drainage, with a recurrence rate of up to 44% associated with inadequate drainage 3

Antibiotics are not routinely indicated after adequate surgical drainage, but are recommended for severe or extensive disease, rapid progression with associated cellulitis, signs and symptoms of systemic illness or sepsis, immunosuppression, significant comorbidities, extremes of age, abscess in difficult-to-drain locations, associated septic phlebitis, or lack of response to I&D alone, as recommended by the Infectious Diseases Society of America 1, 2

For outpatients with purulent drainage requiring antibiotics, empirical coverage for community-acquired MRSA is recommended pending culture results, with options including clindamycin, trimethoprim-sulfamethoxazole, tetracycline, and linezolid, with a recommended duration of 5 to 10 days 1, 2, 4

For hospitalized patients with complicated skin and soft tissue infections, empirical IV therapy for MRSA should be considered in addition to surgical debridement, with options including vancomycin, linezolid, daptomycin, and telavancin, with a recommended duration of 7 to 14 days 1, 2, 4

Sampling of drained pus should be performed in high-risk patients and/or in the presence of risk factors for multidrug-resistant organism infection, including immunocompromised patients, those with healthcare-associated infections, or those who fail initial therapy, as recommended by the World Journal of Emergency Surgery 5, 3

Rifampin should not be used as single agent or adjunctive therapy for skin and soft tissue infections, and probing for fistulas during acute abscess drainage should be avoided, as recommended by the Infectious Diseases Society of America 1, 2, 4
Delaying drainage if imaging is not immediately available when an abscess is clinically suspected should be avoided, and the extent of infection should not be underestimated, with complete drainage necessary to prevent recurrence 3