Management of Abscesses

Clinical Assessment and Decision Algorithm

The American College of Physicians and Infectious Diseases Society of America recommends incision and drainage as the definitive treatment for simple cutaneous abscesses in immunocompetent patients 1, 2.
The Infectious Diseases Society of America suggests that most large furuncles and all carbuncles should be treated with incision and drainage 1.
Antibiotics are unnecessary unless fever or systemic signs of infection are present, as stated by the Infectious Diseases Society of America 1, 2.

A step-up diagnostic approach should be used for deep or intra-abdominal abscesses, starting with clinical and laboratory examination, then proceeding to imaging based on clinical suspicion and available resources, as recommended by the World Journal of Emergency Surgery 3.
CT with IV contrast is indicated when deep abscess is suspected to confirm diagnosis, determine size, and guide treatment strategy, according to the World Journal of Emergency Surgery 4, 5.

Small abscesses (<3-5 cm) may be treated with antibiotics alone in immunocompetent, clinically stable patients, as suggested by the World Journal of Emergency Surgery 4, 7.
Large abscesses (>5 cm) should be treated with percutaneous drainage combined with antibiotics as the preferred initial approach, according to the World Journal of Emergency Surgery 4, 7.
In critically ill or immunocompromised patients, surgical intervention should be considered as primary treatment, as recommended by the World Journal of Emergency Surgery 4.

CBC should be obtained selectively, not routinely, and is indicated in patients with systemic signs of infection to assess for SIRS criteria, as stated by the Infectious Diseases Society of America 1, 2.
Elevated WBC count and inflammatory markers help guide antibiotic duration and need for intervention, according to the World Journal of Emergency Surgery 4.

Delaying drainage of accessible abscesses while waiting for imaging or laboratory results in clinically stable patients should be avoided, as recommended by the Infectious Diseases Society of America and the World Journal of Emergency Surgery 1, 6.
Surgical exploration as initial management should not be performed unless the patient is hemodynamically unstable with peritonitis or the abscess is not amenable to percutaneous drainage, as stated by the World Journal of Emergency Surgery 8, 7.