Abscess Care

I don't irrigate. I've been told it can push the bacteria deeper. I suppose that the fact that I do irrigate wounds migh be contradictory except that your dealing with a known area of infection vs. an area with surface contamination. I pack with non-iodonated gauze. Been told the iodine kills fibroblasts and inhibits healing. I do culture and Rx antibiotics since the big MRSA push thus insuring that Keflex and Bactrim will be useless soon. Since I'm culturing I usually use the culturette swab to deloculate the abscess.

None of this is EBM. It's what I was taught in residency but I'm positive all of my professors' practices were firmly grounded in EBM.

One thing that seems like a heckuva good idea to me (and which is endorsed by Rosen's I think) is to use a sentinel needle if you're going to cx the nasty.

I have been told my numerous PhD clinical micros that ANYTHING is better than a swab so the few times I've done this I have just aspirated some of the crap into the syringe, capped the needle and sent it down.

I figure if you've already numbed the person up one more little poke won't hurt -- although I'd imagine you'd want to use a decent sized needle. I just had the thought of using an ABG kit since they have those little caps, the needle might be a bit to thin but I think I'm going to try it next time anyway.

I sent down some pus from a wound infection this way (aspirating into a sterile syringe) and then called down to make sure it was ok, the techs told me fluid was great and better than swabs any day. Your results may vary.


FWIW: I've never been told to irrigate an abscess.

AmoryBlaine said:

One thing that seems like a heckuva good idea to me (and which is endorsed by Rosen's I think) is to use a sentinel needle if you're going to cx the nasty.

I have been told my numerous PhD clinical micros that ANYTHING is better than a swab so the few times I've done this I have just aspirated some of the crap into the syringe, capped the needle and sent it down.

I figure if you've already numbed the person up one more little poke won't hurt -- although I'd imagine you'd want to use a decent sized needle. I just had the thought of using an ABG kit since they have those little caps, the needle might be a bit to thin but I think I'm going to try it next time anyway.

I sent down some pus from a wound infection this way (aspirating into a sterile syringe) and then called down to make sure it was ok, the techs told me fluid was great and better than swabs any day. Your results may vary.


FWIW: I've never been told to irrigate an abscess.

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We (I) irrigate all abscesses. This is engrained in our heads from out ortho colleagues who say it is the most important thing to do. No evidence probabably.

Never use a sentinel needle. Always get CA-MRSA off the cultures we do with regular cultures (since our rate is around 80%).

Pack with whatever the nurses give me iodoform or not.

antibiotics only if surrounding cellulitis. If nice clean abscess then draining is curative usually.

agree that there is variation in care here.

later

For another variation on the theme, we have started using vessel loops on all our pediatric abscesses, and it is carrying over to the adults. The peds surgeons started it, and we started it at their insistance - and we love it. We use the blue vessel ties that the vascular surgeons use, make two small incisions on either side of the abscess (or the top and a side), break up as many loculations as possible, and thread the plastic through. (Use an ear curette loop as a "needle" or a pair of kellys.) Tie the ends, and have them f/u with our peds surgeon or return to ED (grownups) for removal in 1 week. Self-draining, easy to care for, no need to mess with packing.

Some I still drain and pack (iodoform). I don't irrigate. I rarely culture, as we all know what it is - unless the PCP or admitting team requests it. But I love the loop management. I have heard of some using penrose drains similarly, but the vessel loops are smaller.

The use of a vessel loop is common practice in colorectal surgeon as a seton placement for fistulae.

Interesting about the irrigation. I cannot imagine a surgeon NOT irrigating...as a matter of fact, in the OR, if available, I'll use a Stryker pulsed lavage for large abscesses (got it from the Ortho guys). Most of the time it takes too much time to get or when in a outpatient area, so simple flooding of the area after breaking down the loculations. I am not aware of any good evidence that irrigation pushes bacteria further into the tissues. The problem I see more is people failing to pack the wound or otherwise keep it open (this is generally more of a problem with allied health care workers than with physicians).

The "solution to pollution is dilution".

"piss and puss must pass".


Don't irrigate.

I&D

Pack with whatever.

Abx if surrounding cellulitis.

I often use ultrasound to make sure there is pus before lancing someone open with a scalpel.

roja;

does an abscess just look like a fluid filled structure on U/S, or is it that disorganized cloudy mess because of the particulate matter involved? I've never put a probe on an abscess. I might have to try it next time I get an nice pilonidal

BTW, I usually just open it, break up loculations, and pack with plain 1/4 inch gauze. I only start antibiotics if there is surrounding cellulitis. Have them follow-up in 2 days for packing removal and re-assessment. If I don't see them for follow-up, I often find that they are started on bug-juice even though I didn't think it was necessary and it is well documented in my chart. Don't know if this is personal preference or patient pushing for it. Either way, it kinda bothers me...

[/rant]

No irrigation. Simple I&D (with packing if large). I give antibiotics to everyone now due to the huge incidence of MRSA, coupled with our population's poor follow-up and propensity for litigation.

Dr.McNinja said:

I learned this one this year as a surgeon-of-sorts. Either cut a huge X, or cut out a crescent (cat's eye) shape so that the edges don't close up as quickly when the patients decide that packing hurts too much.

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I've heard that too but I think most of us are taught NOT to cut X's for wound healing reasons.

The only exception I've heard is for peri-rectals that are managed in the ED. A colorectal surgeon once lectured me to cut an X and then cut flaps off each quadrant to leave the thing wide open.

Good discussion though. I will unabashedly admit that I love doing I&D's.

It seems like the consensus of the EPs is to not irrigate yet the surgeon (the venerable WS) says absolutely irrigate. Since surgeons are the specialists we send abscesses to for follow up and we consult them for treatment when they're to big or complicated for ED I&D why are we not doing it their way? Is there surgical lit that's better than ours? Ours is pretty scant.

I was under the impression that irrigation was for removing foreign particulate matter from wounds, not simply for diluting bacteria. Which is why it doesn't matter if the water is sterile or not. So it should be different from irrigating abscesses in that theory. I'll read up on it and see what I get.

That's what I was saying earlier. We irrigate all abscesses, but we learn that from our surgery/ortho guys who do tons of abscesses.

And we never use the X incision. Have been told that is very outdated and makes for a horrible scar that is unnecessary.

later

Yes, it looks like fluid. Basically a pocket of black on the probe. I prefer the high frequency probe.

Here's some info about I&D from UptoDate:

MANAGEMENT — Most patients with skin abscesses in the early stages of development can be treated with warm compresses to promote spontaneous drainage. Surgical drainage is required if spontaneous drainage does not occur or antibiotic treatment does not achieve resolution of the lesion(s) [1-3] . (See "Skin abscesses, furuncles and carbuncles").

Culture — In the past, purulent material obtained from a spontaneously draining wound or from incision and drainage was not always sent for culture because drainage was usually curative. However, we recommend a change in this practice because community-associated methiciliin-resistant S. aureus (MRSA) infections now account for the majority of skin of skin abscesses in many communities. (See "Epidemiology and clinical spectrum of methicillin-resistant Staphylococcus aureus infections in children" and see "Epidemiology of methicillin-resistant Staphylococcus aureus infection in adults").

For abscessed requiring incision and drainage, fluid for cultures should be obtained by needle aspiration through surgically prepared skin before the incision is made [3,4] . This procedure preserves the anaerobic conditions that may be required for certain organisms to grow. (See "Microbiology specimen collection and transport", section on Specimen collection).


Antibiotic therapy — Decisions about antibiotic therapy must address both the need for endocarditis prophylaxis and for therapy of the abscess. These issues are discussed separately. (See "Skin abscesses, furuncles and carbuncles", section on Management).

Procedure — The incision can be performed with a No. 11 or 15 scalpel blade after adequate anesthesia is achieved. A simple linear incision is made through the total length of the abscess. The incision should conform with the natural folds of the skin. Cruciate or elliptical incisions should be avoided because they can cause unsightly scars. A stab incision may be used to limit tissue injury and scarring if the abscess is in a cosmetic area or an area of skin tension.

After incision, the abscess cavity should be probed with a hemostat wrapped in gauze to break loculations, identify foreign bodies, and ensure proper drainage. The wound should not be probed with a gloved finger or scalpel. A gloved finger may be injured by a sharp foreign body, while use of a scalpel may cause tissue damage or create a false passage or fistula. Probing of the wound is painful and may require additional anesthesia. Irrigation of the wound may be performed but has not been proven to augment healing or to affect the outcome [1] . (See "Minor wound preparation and irrigation", section on Irrigation).

After probing and/or irrigation, the remaining cavity should be loosely filled with a gauze packing strip. A tail of about 1 cm of packing strip will serve as a wick for drainage and facilitate subsequent removal of the packing material [10] . The wound is then dressed with an absorbent dressing.

There was a fairly good review done and published (Annals or Journal) ~6-10 months ago. I didn't keep the article, but it did go over several studies that discussed irrigation with saline (i think), that in the end showed no difference.

I'll look for the reference.....
I think this is the article.... +/-
http://www.annemergmed.com/article/PIIS0196064407000789/fulltext

Everyone should remember that "just because surgeons do it" shouldn't be a valid argument. Surgeons are notorious for being traditionalists rather than practicing EBM.

Some non-EBM surgery dogma:

1. Washing out the abdomen with antibiotics before closure will improve healing
2. Keeping a sterile field for lac repairs reduces infections versus aseptic technique
3. Morphine causes sphincter of Odi spasm
4. Pain meds should not be given to appys because it will "change the exam"
5. 5 years of residency is "cool" and "fun"

when I worked in a veterinary pathology lab we were taught (as techs, usually doing necropsies) with abscesses, if you culture, not to take puss, but swab the outer edges of the lesion. The argument was that the innermost part of the infection will be mostly WBC rather than bacteria and there was a better chance of catching bacteria around the periphery.

We definately don't give antibioitics to all abscesses.

We have a large NIH grant to look MRSA/abscess care. We unfortunately, have the highest rate of MRSA in the country (whoo hoo).

Antibiotics only to those with surrounding cellulitis.


Simple abscesses althought always MRSA are still treated with I and D.

why are people giving antibiotics to ALL abscesses? Has there been a change in practice that I'm not aware?

really just curious because we rarely prescribe antibx and we do probably 20/day and I rarely admit folks on follow up for failed therapy on our wound checks. almost all do fine with just simple i and d.

later

njac said:

when I worked in a veterinary pathology lab we were taught (as techs, usually doing necropsies) with abscesses, if you culture, not to take puss, but swab the outer edges of the lesion. The argument was that the innermost part of the infection will be mostly WBC rather than bacteria and there was a better chance of catching bacteria around the periphery.

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I doubt that.

I agree with 12R34Y,
Once again, there is some limited published data that Abx are not much of a help unless there is surrounding cellulitis, and even then only if a certain size (I can't remember but I'll find the study, something like >4cm surrounding cellulitis get abx).

I'll look for the study.

GeneralVeers said:

Everyone should remember that "just because surgeons do it" shouldn't be a valid argument. Surgeons are notorious for being traditionalists rather than practicing EBM.

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True. Although I would venture that some of what you've listed below was practiced in your institution because with the exception of the old-timers citing #s 3 and 4, I've never heard of #s 1 and 2. And the vast majority of younger surgeons I know do none of the below:

Some non-EBM surgery dogma:

1. Washing out the abdomen with antibiotics before closure will improve healing
2. Keeping a sterile field for lac repairs reduces infections versus aseptic technique
3. Morphine causes sphincter of Odi spasm
4. Pain meds should not be given to appys because it will "change the exam"
5. 5 years of residency is "cool" and "fun"

Click to expand...

Except 5 because THAT is true.

I'd much rather have done 5+ years of a surgical residency (as hellish as it could be) than 3 years of something I didn't care for.

Anyway, like roja, I will usually US and look for a hypoechoic area. If its large enough you can see a fluid wave sometimes with floating debris.

No antibiotics unless systemically ill and/or cellulitis.

No cruciate or ellipse (although I had attendings who still did it that way). Nice linear incision at the point of maximal fluctuance, perferably in a skin crease or Langer's.

If needed, a closed suction drain is safer than a Penrose unless drain is just staying in overnight (then it doesn't matter what the skin flora crawl in on - Ribbon gauze or Penrose). I'm frankly not a fan of any drains staying in these. I'd rather thread Kerlex through with a sponge stick and change it everyday.

And there may not be good evidence for irrigation and perhaps its dogma, but something just *feels* right to me about washing out all that nasty stuff.

emedpa said:

what % of your abscess pts use heroin or meth or are otherwise immunocompromised? our # is probably something like 75% +.....not a great group for compliance...they often have multiple and/or recurrnet abscesses, leave drains in for extended periods, don't make f/u appts, etc...our i.d. chief wants 100% of these cultured and given abx

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Off the top off my head probably close to 100%. (teasing, but easily as high as 75% as well).

work in an entirely county/inner city/urban/ghetto. also no follow up.

however, we still find simple I and D is still the definitive treatment for these guys.

Even with our poor follow up rate I rarely admit someone for failed outpatient treatment after an I and D.

I and D's fix these guys. I don't think there is any evidence that antibiotics help abscesses, even MRSA.

OH, well, our ginormo NIH study on MRSA/abscesses with ID net should shed some light on some of this crap hopefully in the future.

later

emedpa said:

not a great group for compliance...... don't make f/u appts, etc..

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So what makes you think they are going to take a full course of ABX. Seems to me that by giving all these guys ABX, you are increasing the chances of causing resistance to the few cheap abx that actually work against CA-MRSA....

Sounds like bad practice to me....

Winged Scapula said:

True. Although I would venture that some of what you've listed below was practiced in your institution because with the exception of the old-timers citing #s 3 and 4, I've never heard of #s 1 and 2. And the vast majority of younger surgeons I know do none of the below:



Except 5 because THAT is true.

I'd much rather have done 5+ years of a surgical residency (as hellish as it could be) than 3 years of something I didn't care for.

Anyway, like roja, I will usually US and look for a hypoechoic area. If its large enough you can see a fluid wave sometimes with floating debris.

No antibiotics unless systemically ill and/or cellulitis.

No cruciate or ellipse (although I had attendings who still did it that way). Nice linear incision at the point of maximal fluctuance, perferably in a skin crease or Langer's.

If needed, a closed suction drain is safer than a Penrose unless drain is just staying in overnight (then it doesn't matter what the skin flora crawl in on - Ribbon gauze or Penrose). I'm frankly not a fan of any drains staying in these. I'd rather thread Kerlex through with a sponge stick and change it everyday.

And there may not be good evidence for irrigation and perhaps its dogma, but something just *feels* right to me about washing out all that nasty stuff.

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Completely naive question: isn't it exceedingly rare to become "systemically ill" from an abscess?

Do you actually see people in sepsis/shock etc for whom the nidus of infection appears to be a whopping abscess?

AmoryBlaine said:

Completely naive question: isn't it exceedingly rare to become "systemically ill" from an abscess?

Do you actually see people in sepsis/shock etc for whom the nidus of infection appears to be a whopping abscess?

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Yes. Not all the time, but I have seen people quite sick that recover nicely after a good I+D and some IV abx.

I have done both simple bedside I+D's and more extensive operative ones. I have also had the pleasure of dealing with inadequately drained ones from my colleagues in the ED. Here are a couple of things I firmly believe in:

1. Simply sticking a needle in an abscess is not a good idea as definitive treatment.

2. If the diameter of fluctuance is more than about a centimeter, you need to actually cut with the scalpel, not just stab an 11 blade in there.

3. If your incision is large enough you have a better chance of a good outcome even with a noncompliant patient.

4. Lots of people can be convinced to tuck the corner of a 2x2 between the skin edges after a daily shower, even those who would balk at actually shoving packing gauze in the cavity (and it can be accomplished by parents of lots of kids with less crying all around).

AmoryBlaine said:

Completely naive question: isn't it exceedingly rare to become "systemically ill" from an abscess?

Do you actually see people in sepsis/shock etc for whom the nidus of infection appears to be a whopping abscess?

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Rare, yes. But I have seen it. Part of why in a sepsis work up, you should always do a head-to-toe to look for skin infections.

AmoryBlaine said:

Completely naive question: isn't it exceedingly rare to become "systemically ill" from an abscess?

Do you actually see people in sepsis/shock etc for whom the nidus of infection appears to be a whopping abscess?

Click to expand...

Don't forget the diabetics - a "simple" skin abscess can trigger/compound a nasty case of DKA.

AmoryBlaine said:

Completely naive question: isn't it exceedingly rare to become "systemically ill" from an abscess?

Do you actually see people in sepsis/shock etc for whom the nidus of infection appears to be a whopping abscess?

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Yes, like the others I have seen it and would not classify it as exceedingly or even just plain old rare.

As a matter of fact, a friend of mine ended up with endocarditis (requiring a valve replacement) and a brain abscess after an I&D (done by another resident) of an axillary abscess.

We not infrequently see patients in the ICU with huge abscesses and septic shock. It can happen to anyone but especially diabetics and those who are immunocompromised. Others with abscesses in highly vascular areas like the face and the perineum are prone to sepsis and its why I look for and ask about these things, because it can be the difference btween who goes home on PO abx and who stays for IV abx etc.

TysonCook said:

There was a fairly good review done and published (Annals or Journal) ~6-10 months ago. I didn't keep the article, but it did go over several studies that discussed irrigation with saline (i think), that in the end showed no difference.

I'll look for the reference.....
I think this is the article.... +/-
http://www.annemergmed.com/article/PIIS0196064407000789/fulltext

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This post bears repeating and this article bears reading as well. This is a great review of 3 pretty decent studies that were done regarding I&D of abcesses...The long and the short of it is that abcessess should be I&D'ed, but NO ABX ARE NECESSARY!!! The definitive treatment for an abcess is to I&D it. This included populations with a very high occurance of MRSA and patients who are immunocompromised (diabetics, IVDA, etc)...the only possible exception are those patients with a LARGE (not just some but LARGE) area of surrounding cellulitis.

Don't routinely give abx to a pt whose abcess you have drained

As far as exact technique for draining, the article does not really go into it. Just open it wide ;-)

DocFrog said:

This post bears repeating and this article bears reading as well. This is a great review of 3 pretty decent studies that were done regarding I&D of abcesses...The long and the short of it is that abcessess should be I&D'ed, but NO ABX ARE NECESSARY!!! The definitive treatment for an abcess is to I&D it. This included populations with a very high occurance of MRSA and patients who are immunocompromised (diabetics, IVDA, etc)...the only possible exception are those patients with a LARGE (not just some but LARGE) area of surrounding cellulitis.

Don't routinely give abx to a pt whose abcess you have drained

As far as exact technique for draining, the article does not really go into it. Just open it wide ;-)

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I'm becoming more of a fan of the elective script option similar to what I do with kids with OM. Give them a script, tell them to wait a day or so to see if it improves, and if it doesn't, then get the script filled. Works wonders for patient satisfaction, and most people are responsible enough to wait and see if it starts to get better.

I REALLY like this idea of Rx and fill if necessary.....hmmm....research project anyone? Not sure what others think but in theory could be a bonus for both PT satisfaction AND decrease ABx resistance

How common is it to have a relatively small abscess/phlegmon and large area of cellulitis? Does that point you toward a particular bug?

I had a pt with definite R thigh cellulitis (about 5cm diameter) and SIRS with no other source of infection, but on ultrasound the collection was 1cm in diameter with lots of surrounding cellulitis.

Because of the size we did not I&D, but started IV Vanc and fluids, and admitted.

Any thoughts? Any additional references would be icing on the cake.

BTW According to a recent study a central black eschar is 55% sens and 92% spec for CA-MRSA.

TysonCook said:

I REALLY like this idea of Rx and fill if necessary.....hmmm....research project anyone? Not sure what others think but in theory could be a bonus for both PT satisfaction AND decrease ABx resistance

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Hmm...that is a great idea for a research project.

Winged Scapula, The friend c endocarditis and brain abscess, please tell me it was a more complicated initial clinical picture rather than a simple cut squeeze pack abscess that caused that.

In medical school, I learned the elliptical with irrigation and daily packing changes. Now I use a more linear elliptical (remove tiny amount of skin) for packing room......anyways moving towards a more evidenced based approach since the elliptical seems out of date