Management of Traumatic Forearm Abscess

Primary Treatment: Incision and Drainage

The American College of Physicians and the Infectious Diseases Society of America recommend incision and drainage as the definitive treatment for traumatic forearm abscess, with antibiotics added only if the patient demonstrates systemic signs of infection, according to the SIRS criteria 1, 2
The primary therapy for any cutaneous abscess is incision and drainage, which is non-negotiable, as stated by the Infectious Diseases Society of America 3, 1
Thoroughly evacuate all pus and probe the cavity to break up loculations, as recommended by the Clinical Infectious Diseases guidelines 4
For larger abscesses (>5 cm), use multiple counter-incisions rather than one long incision to prevent step-off deformity and delayed healing, as suggested by the Clinical Infectious Diseases guidelines 4
Simply cover with a dry sterile dressing, as packing may cause more pain without improving healing, according to the Clinical Infectious Diseases guidelines 2

Antibiotics are not routinely needed after adequate drainage, as stated by the Infectious Diseases Society of America 3, 1, 2
The decision to use antibiotics hinges entirely on whether systemic inflammatory response syndrome (SIRS) is present, according to the Clinical Infectious Diseases guidelines 3, 1, 2
No antibiotics are needed if the patient has a temperature <38.5°C, heart rate <100 beats/min, white blood cell count <12,000 cells/µL, and minimal surrounding erythema (<5 cm), as recommended by the Infectious Diseases Society of America 3, 4
Add antibiotics if any of the SIRS criteria are present, including temperature >38°C or <36°C, tachycardia >90 beats/min, tachypnea >24 breaths/min, or WBC >12,000 or <4,000 cells/µL, as suggested by the Clinical Infectious Diseases guidelines 1, 2, 5

Empiric coverage should target both S. aureus (including MRSA) and streptococci, as recommended by the Infectious Diseases Society of America 1, 5
Consider vancomycin or another anti-MRSA agent (daptomycin, linezolid) if SIRS is present, according to the Clinical Infectious Diseases guidelines 1, 5
The duration of antibiotic treatment should be 5-7 days based on clinical response, as suggested by the Praxis Medical Insights guidelines 4

Do not attempt needle aspiration, as it has only a 25% success rate overall and <10% with MRSA, according to the Clinical Infectious Diseases guidelines 2, 4
Do not give antibiotics without adequate drainage, as studies show no benefit when drainage is incomplete, as stated by the Infectious Diseases Society of America 3
Do not assume antibiotics alone will work, as the primary pathology is a collection requiring mechanical evacuation, according to the Infectious Diseases Society of America 3, 1

Obtain Gram stain and culture of the pus if you proceed with I&D, though treatment without these studies is reasonable in typical cases, as recommended by the Clinical Infectious Diseases guidelines 2
This is particularly important given the traumatic etiology (possible foreign material or unusual organisms) and the rising prevalence of community-acquired MRSA, according to the Infectious Diseases Society of America 1, 2

Re-evaluate at 7 days, and if signs of infection persist beyond this timeframe, diagnostic re-evaluation is warranted, as suggested by the Praxis Medical Insights guidelines 4
Patients with ongoing fever or failure to improve indicate inadequate source control, requiring repeat imaging or intervention, according to the Praxis Medical Insights guidelines 4