Management of Abscesses and Carbuncles

Initial Treatment

Incision and drainage is the definitive treatment for abscesses and carbuncles, and should be performed as soon as the diagnosis is made, with strong recommendation and high-quality evidence 1
Perform incision and drainage for all carbuncles, abscesses, and large furuncles as the cornerstone of treatment with strong recommendation and high-quality evidence 1
Make the incision as close as possible to the affected area to ensure adequate drainage while avoiding damage to important structures 2
Thoroughly evacuate all purulent material and probe the cavity to break up any loculations 3
Cover the surgical site with a dry sterile dressing rather than packing with gauze, as this is more effective for wound healing 3, 4
Obtain Gram stain and culture of the pus, though treatment without these studies is reasonable in typical uncomplicated cases 1, 3

Systemic antibiotics should be added as an adjunct to I&D when any of the following are present: systemic inflammatory response syndrome, extensive surrounding cellulitis, multiple lesions, or markedly compromised host defenses 1, 4
The American College of Physicians recommends considering antibiotic therapy for patients with abscesses or carbuncles who have systemic signs of infection or are immunocompromised 1
For Methicillin-Sensitive Staphylococcus aureus (MSSA), dicloxacillin 500 mg orally every 6 hours is recommended as first-line therapy 3, 4
For Methicillin-Resistant Staphylococcus aureus (MRSA) or suspected MRSA, clindamycin 300-450 mg orally every 6 hours is recommended as first-line therapy 3, 4
The duration of antibiotic therapy should be 5-10 days for mild to moderate infections after adequate source control 4

Young, fit patients without signs of sepsis may have their procedure performed in an ambulatory outpatient setting 2
Small simple perianal abscesses may be treated under local anesthesia 2
Emergency drainage is required if the patient has sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis 2
Critically ill patients require emergent drainage and broader antibiotic coverage may be needed based on clinical severity 2

Mupirocin intranasal application twice daily for 5 days is recommended for decolonization 3, 4
Daily chlorhexidine baths and daily decontamination of personal items are also recommended for decolonization 3, 4
Screen for diabetes mellitus and assess for immunodeficiency states in patients with recurrent abscesses or carbuncles 3

Do not rely on needle aspiration alone, as it has only a 25% success rate and is not recommended as definitive treatment 4
Do not use antibiotics as monotherapy without drainage for formed abscesses or carbuncles 1, 3
Inadequate drainage is the most common cause of recurrence, and failure to probe and break up loculations leads to treatment failure 2, 3