Management of Incision and Drainage with Packing for Abscesses

Primary Management Approach

Incision and drainage (I&D) is the cornerstone treatment for abscesses, with complete evacuation of infected material, as recommended by the Infectious Diseases Society of America 2, 3
Gram stain and culture of pus from abscesses are recommended to guide antibiotic therapy if needed, though treatment without these studies is reasonable in typical cases, according to the Infectious Diseases Society of America 2

The Infectious Diseases Society of America recommends that antibiotics are not required for simple abscesses with successful I&D, abscesses less than 5 cm in diameter, no systemic inflammatory response syndrome (SIRS), immunocompetent patients, and no significant surrounding cellulitis 1, 4, 5, 2
Antibiotics are indicated when SIRS is present, erythema extends more than 5 cm from the wound edge, the patient is immunocompromised, the abscess is in a difficult-to-drain area, or there is septic phlebitis, as recommended by the Infectious Diseases Society of America 5, 2, 1

For skin/soft tissue abscesses, the Infectious Diseases Society of America recommends first-line empiric treatment with TMP-SMX or doxycycline for CA-MRSA coverage, with alternative options including clindamycin, and vancomycin for severe infections 6, 2
For surgical site infections, the Infectious Diseases Society of America recommends various antibiotic regimens based on the anatomical location of the surgery, including oxacillin/nafcillin, cefazolin, cephalexin, and TMP-SMX for trunk or extremity surgeries, and piperacillin-tazobactam or ertapenem for intestinal or genitourinary tract surgeries 5, 6

The Infectious Diseases Society of America recommends a duration of therapy of 5-10 days for simple abscesses requiring antibiotics, and 7-14 days for complicated infections with systemic symptoms, based on clinical response 7, 5

For recurrent abscesses, the Infectious Diseases Society of America recommends a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items, to reduce the risk of future infections 7
Methicillin-resistant S. aureus (MRSA) is a common pathogen in community-acquired abscesses and should be considered when selecting empiric therapy, as recommended by the Infectious Diseases Society of America 6

Inadequate drainage is a common pitfall, and the Infectious Diseases Society of America recommends ensuring complete evacuation of purulent material, which is more important than antibiotic selection in most cases 5, 2
Unnecessary antibiotics should be avoided, as simple abscesses that have been adequately drained often do not require antibiotics, according to the Infectious Diseases Society of America 1
Failure to culture is another pitfall, and the Infectious Diseases Society of America recommends that cultures should guide therapy, especially in areas with high MRSA prevalence 2
Underlying conditions such as diabetes, immunosuppression, or foreign material should be evaluated in cases of recurrent abscesses, as recommended by the Infectious Diseases Society of America 7