Cutaneous abscess medical therapy

Abscess Main page
Patient Information
Overview
Causes
Classification Anal Abscess Appendicular Abscess Brain Abscess Breast Abscess Colon Abscess Cutaneous Abscess Liver Abscess Lung Abscess Pancreatic Abscess Retropharyngeal Abscess Splenic Abscess Tonsillar and Peritonsillar Abscess
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Treatment of abscess depends on the type of infection. The antibiotic sensitive for MRSA is used to treat recurrent abscess. Antibiotics along with surgical drainage is the most effective way of treating the abscess.

Medical Therapy

Antibiotics

As Staphylococcus aureus bacteria is a common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels.

A clinical practice guideline by the Infectious Disease Society of America concludes that "Gram stain, culture, and systemic antibiotics are rarely necessary"; however, according the National Guideline Clearinghouse summary of this guideline, the guideline was not a systematic review of the evidence.

Antibiotics should be considered if there is significant overlying cellulitis. Systematic reviews of relevant studies concluded that:

"the current literature does not support the routine practice of prescribing antibiotics after incision and drainage of simple cutaneous abscesses, even in high-MRSA-prevalence areas"

"our conclusions cannot be extrapolated to those cases in which there is a significant degree of overlying cellulitis"

Randomized controlled trials

There are conflicting randomized controlled trials to guide the decision for antibiotics. The largest trials found benefit from trimethoprim–sulfamethoxazole versus placebo. Some trials are undersized.The strongest support for using antibiotics is from a trial of clindamycin. and a trial of trimethoprim-sulfamethoxazole. The strongest refutations of antibiotics were a trial of cephradine and maybe an older trial of penicillin. In the most recent trial, although 87.8% of isolates were methicillin-resistant staphylococcus aureus (MRSA), the antibiotic used was cephalexin which is inactive against MRSA. It is not known if an antibiotic effective against MRSA would have reducted the rate of treatment failures below the 10% failure rate observed in the trial. However, the clindamycin trial above and one cohort study below suggests effective antibiotic therapy helps.

Additional trials exit, however, one did not have a placebo group. A pediatric trial found short term benefit from trimethoprim-sulfamethoxazole after incision and drainage.

For infected wounds, clindamycin and trimethoprim-sulfamethoxazole may be similar. .

No trial has separately reported the role of antibiotics for large abscesses (> 5 cm). Large abscesses may be less likely to respond without antibiotics.

Recurrent infections

Recurrent abscesses are often caused by community-acquired MRSA. While resistant to most beta lactam antibiotics commonly used for skin infections, it remains sensitive to alternative antibiotics, ie clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), and doxycycline (unlike hospital-acquired MRSA that may only be sensitive to vancomycin IV).

To prevent recurrent infections due to Staphylococcus, consider the following measures:

• Topical mupirocin applied to the nares . In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.
• Chlorhexidine baths , In a randomized controlled trial, nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach statistical significance, the baths are an easy treatment.

Magnesium Sulphate Paste

Historically abscesses as well as boils and many other collections of pus have been treated via application of magnesium sulfate paste. This works by drawing the infected pus to the surface of the skin before rupturing and leaking out, after this the body will usually repair the old infected cavity. Magnesium sulphate is therefore best applied at night with a sterile dressing covering it, the rupture itself is not painful but the drawing up may be uncomfortable. Magnesium sulphate paste is considered a "home remedy" and is not necessarily an effective or accepted medical treatment.

Treatment Regimen

Splenic abscess

• 1. Endocarditis, bacteremia

• Preferred regimen: Nafcillin or Oxacillin 2 gm IV q4h if MSSA
• Alternative regimen: Vancomycin 1 gm IV q12h if MRSA

• 2. Contiguous from intra-abdominal site

• 2.1. Mild-moderate disease

• Preferred regimen (1): Piperacillin-tazobactam 3.375 g IV q6h or 4.5 g IV q8h
• Preferred regimen (2): Ticarcillin-clavulanate 3.1 g IV q6h
• Alternative regimen: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h AND Metronidazole 1 g IV q12h.

• 2.2. Severe life-threatening disease

• Preferred regimen (1): Imipenem 500 mg IV q6h
• Preferred regimen (2): Meropenem 1 g IV q8h

• 3. Immunocompromised

• Preferred regimen: Amphotericin B 0.7 mg/kg IV daily
• Alternative regimen (1): Fluconazole 800 mg (12 mg/kg) loading dose, then 400 mg daily IV or PO
• Alternative regimen (2): Caspofungin 70 mg IV loading dose, then 50 mg IV daily (35 mg for moderate hepatic insufficiency);