Effectiveness of Outpatient Antibiotics After Surgical Drainage of Abscesses in Reducing Treatment Failure

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BACKGROUND

Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.

OBJECTIVE

This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.

DISCUSSION

Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.

CONCLUSIONS

This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.

Decreasing the Duration of Discharge Antibiotic Treatment Following Inpatient Skin and Soft Tissue Abscess Drainage

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Introduction:

Skin and soft tissue abscesses do not require prolonged systemic antimicrobial treatment following drainage. We aimed to decrease the duration of discharge antibiotic treatment to less than 5 days following inpatient incision and drainage of uncomplicated abscesses.

Methods:

A new treatment protocol that defined uncomplicated abscesses, as well as inclusion and exclusion criteria, was created to monitor the accurate duration of prescribed therapy at discharge. We implemented a treatment algorithm that takes into account the epidemiologic changes in microbial etiologies and the presence of systemic findings for patients after surgical incision and drainage. We used control charts to assess the impact of the interventions.

Results:

Four hundred and eighteen patients were discharged following abscess drainage from our inpatient infectious diseases unit in 2016. The patients were 3 months to 21 years of age. Only 72 (17%) patients had prescribed discharge antibiotic treatment courses that were less than 5 days [range 0–31 days, median 8 days (IQR 6, 9)], and the average prescribed course at discharge was 8.6 days. During the study period, we significantly decreased the average duration of discharge antibiotics to 7.3 days in all patients (P = 0.0016, 95% CI: −2.1036 to −0.4964, difference of means −1.3). The discharge treatment duration of patients with uncomplicated abscess was shorter at 4.7 days [range 0–9 days, median 5 days, (IQR 3, 5)]. Prescription compliance to less than 5 days treatment course at discharge increased from the baseline of 17% to 42% overall.

Conclusions:

Standardizing definitions of uncomplicated skin and soft tissue abscesses was critical to the success of this project. In addition to possible improved treatment adherence and decreased side effects, our protocol led to decreased patient care costs with no documented changes in readmission rates.