Abscess: Difference between revisions

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A more recent [[randomized controlled trial]] confirms these results<ref name="pmid17846141">{{cite journal |author=Rajendran PM, Young D, Maurer T, ''et al'' |title=Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection |journal=Antimicrob. Agents Chemother. |volume=51 |issue=11 |pages=4044–8 |year=2007 |pmid=17846141 |doi=10.1128/AAC.00377-07}}</ref>; although in this trial  87.8% were methicillin-resistant [[staphylococcus aureus]] (MRSA) yet the antibiotic used was [[cephalexin]]. 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. Older trials also are available.<ref name="pmid322789">{{cite journal |author=Macfie J, Harvey J |title=The treatment of acute superficial abscesses: a prospective clinical trial |journal=The British journal of surgery |volume=64 |issue=4 |pages=264–6 |year=1977 |pmid=322789 |doi=}}</ref><ref name="pmid3880635">{{cite journal |author=Llera JL, Levy RC |title=Treatment of cutaneous abscess: a double-blind clinical study |journal=Annals of emergency medicine |volume=14 |issue=1 |pages=15–9 |year=1985 |pmid=3880635 |doi=}}</ref>
A more recent [[randomized controlled trial]] confirms these results<ref name="pmid17846141">{{cite journal |author=Rajendran PM, Young D, Maurer T, ''et al'' |title=Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection |journal=Antimicrob. Agents Chemother. |volume=51 |issue=11 |pages=4044–8 |year=2007 |pmid=17846141 |doi=10.1128/AAC.00377-07}}</ref>; although in this trial  87.8% were methicillin-resistant [[staphylococcus aureus]] (MRSA) yet the antibiotic used was [[cephalexin]]. 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. Older trials also are available.<ref name="pmid322789">{{cite journal |author=Macfie J, Harvey J |title=The treatment of acute superficial abscesses: a prospective clinical trial |journal=The British journal of surgery |volume=64 |issue=4 |pages=264–6 |year=1977 |pmid=322789 |doi=}}</ref><ref name="pmid3880635">{{cite journal |author=Llera JL, Levy RC |title=Treatment of cutaneous abscess: a double-blind clinical study |journal=Annals of emergency medicine |volume=14 |issue=1 |pages=15–9 |year=1985 |pmid=3880635 |doi=}}</ref>
In observational [[cohort study|cohort studies]] of patients with MRSA, one study found there was "no significant differences" (rates not provided by the article) among patients treated with appropriate antibiotics versus those treated without appropriate antibiotics.<ref name="pmid16914702">{{cite journal |author=Moran GJ, Krishnadasan A, Gorwitz RJ, ''et al'' |title=Methicillin-resistant S. aureus infections among patients in the emergency department |journal=N. Engl. J. Med. |volume=355 |issue=7 |pages=666–74 |year=2006 |month=August |pmid=16914702 |doi=10.1056/NEJMoa055356 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16914702&promo=ONFLNS19 |issn=}}</ref> A second [[cohort study]] found that all five (100%) of children treated with appropriate antibiotics improved as compared to 58 of 62 (94%) treated with ineffective antiobiotics.<ref name="pmid14872177">{{cite journal |author=Lee MC, Rios AM, Aten MF, ''et al'' |title=Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus |journal=Pediatr. Infect. Dis. J. |volume=23 |issue=2 |pages=123–7 |year=2004 |month=February |pmid=14872177 |doi=10.1097/01.inf.0000109288.06912.21 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0891-3668&volume=23&issue=2&spage=123 |issn=}}</ref>


==Prevention==
==Prevention==

Revision as of 12:36, 2 January 2009

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An abscess is defined as an "accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection."[1]

Treatment of skin abscesses

Incision and drainage

The abscess should be treated with incision and drainage.[2]

Packing

Although packing of the abscess cavity is commonly done after drainage, it may delay healing.[3] To address this question, a randomized controlled trial was started in Sept. 2008 and is ongoing as of Dec. 2008.[4]

Primary closure

Primary closure has been successful when combined with curettage and antibiotics[5] or with curettage alone.[6] However, another randomized controlled trial found primary closure led to 35% failing to heal primarily and primary closure longer median number of days to closure (8.9 versus 7.8).[7]

In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary healing and recurrence was higher.[8]

Antibiotics

Antibiotics should be considered if there is significant overlying cellulitis. Systematic reviews of relevant studies concluded that:[9][10]

"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"

A clinical practice guideline by the Infectious Disease Society of American concludes that "gram stain, culture, and systemic antibiotics are rarely necessary"[11]; however, according the National Guideline Clearinghouse summary of this guideline, the guideline was not a systematic review of the evidence.[12]

A more recent randomized controlled trial confirms these results[13]; although in this trial 87.8% were methicillin-resistant staphylococcus aureus (MRSA) yet the antibiotic used was cephalexin. 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. Older trials also are available.[2][14]

In observational cohort studies of patients with MRSA, one study found there was "no significant differences" (rates not provided by the article) among patients treated with appropriate antibiotics versus those treated without appropriate antibiotics.[15] A second cohort study found that all five (100%) of children treated with appropriate antibiotics improved as compared to 58 of 62 (94%) treated with ineffective antiobiotics.[16]

Prevention

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

  • Topical mupirocin applied to the nares.[17] In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.[18]
  • Chlorhexidine baths,[19] 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 easy to do.

References

  1. ↑ National Library of Medicine. Abscess. Retrieved on 2007-10-19.
  2. ↑ 2.0 2.1 Macfie J, Harvey J (1977). "The treatment of acute superficial abscesses: a prospective clinical trial". The British journal of surgery 64 (4): 264-6. PMID 322789. [e] Cite error: Invalid <ref> tag; name "pmid322789" defined multiple times with different content
  3. ↑ BestBets: abscesses; to pack or not to pack.
  4. ↑ Study of Wound Packing After Superficial Skin Abscess Drainage - Full Text View - ClinicalTrials.gov.
  5. ↑ Abraham N, Doudle M, Carson P (1997). "Open versus closed surgical treatment of abscesses: a controlled clinical trial". The Australian and New Zealand journal of surgery 67 (4): 173-6. PMID 9137156. [e]
  6. ↑ Stewart MP, Laing MR, Krukowski ZH (1985). "Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial". The British journal of surgery 72 (1): 66-7. PMID 3881155. [e]
  7. ↑ Simms MH, Curran F, Johnson RA, et al (1982). "Treatment of acute abscesses in the casualty department". British medical journal (Clinical research ed.) 284 (6332): 1827-9. PMID 6805714. [e]
  8. ↑ Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up". Acta Chirurgica Scandinavica 150 (8): 689-92. PMID 6397949. [e]
  9. ↑ Hankin A, Everett WW (2007). "Are antibiotics necessary after incision and drainage of a cutaneous abscess?". Annals of emergency medicine 50 (1): 49-51. DOI:10.1016/j.annemergmed.2007.01.018. PMID 17577944. Research Blogging. PMID 17577944
  10. ↑ Korownyk C, Allan GM (2007). "Evidence-based approach to abscess management". Canadian family physician Médecin de famille canadien 53 (10): 1680–4. PMID 17934031. [e]
  11. ↑ Stevens DL, Bisno AL, Chambers HF, et al (November 2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clin. Infect. Dis. 41 (10): 1373–406. DOI:10.1086/497143. PMID 16231249. Research Blogging.
  12. ↑ Anonymous (2005). Practice guidelines for the diagnosis and management of skin and soft-tissue infections.. National Guidelines Clearinghouse.
  13. ↑ Rajendran PM, Young D, Maurer T, et al (2007). "Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection". Antimicrob. Agents Chemother. 51 (11): 4044–8. DOI:10.1128/AAC.00377-07. PMID 17846141. Research Blogging.
  14. ↑ Llera JL, Levy RC (1985). "Treatment of cutaneous abscess: a double-blind clinical study". Annals of emergency medicine 14 (1): 15–9. PMID 3880635. [e]
  15. ↑ Moran GJ, Krishnadasan A, Gorwitz RJ, et al (August 2006). "Methicillin-resistant S. aureus infections among patients in the emergency department". N. Engl. J. Med. 355 (7): 666–74. DOI:10.1056/NEJMoa055356. PMID 16914702. Research Blogging.
  16. ↑ Lee MC, Rios AM, Aten MF, et al (February 2004). "Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus". Pediatr. Infect. Dis. J. 23 (2): 123–7. DOI:10.1097/01.inf.0000109288.06912.21. PMID 14872177. Research Blogging.
  17. ↑ van Rijen M, Bonten M, Wenzel R, Kluytmans J (2008). "Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers". Cochrane Database Syst Rev (4): CD006216. DOI:10.1002/14651858.CD006216.pub2. PMID 18843708. Research Blogging.
  18. ↑ Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y (1996). "A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection.". Arch Intern Med 156 (10): 1109-12. PMID 8638999.
  19. ↑ Watanakunakorn C, Axelson C, Bota B, Stahl C (1995). "Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents.". Am J Infect Control 23 (5): 306-9. PMID 8585642.
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