Abscess, Skin/soft Tissue

Basics

Description

  • A localized collection of pus surrounded and walled off by inflamed tissue. Abscesses can occur on any part of the body
  • Furuncle:
    • Arises from infected hair follicle
    • Most common on back, axilla, and lower extremities
  • Carbuncle:
    • Larger and more extensive than furuncle
  • Dog/cat bite:
    • Usually polymicrobial
  • Breast:
    • Puerperal:
      • Usually during lactation
      • Located in peripheral wedge
      • Usually staphylococci
    • Duct ectasia:
      • Caused by ecstatic ducts
      • Periareolar location
      • Usually polymicrobial
  • Hidradenitis suppurativa:
    • Chronic abscess of apocrine sweat glands
    • Groin and scalp
    • Staphylococcus aureus and staphylococcus viridans are common
    • Escherichia coli and Proteus may be present in chronic disease
  • Pilonidal abscess:
    • Epithelial disruption of gluteal fold over coccyx
    • Staphylococcal species are most common
    • May be polymicrobial
  • Bartholin abscess:
    • Obstruction of Bartholin duct
  • Perirectal abscess:
    • Originates in anal crypts and extends through ischiorectal space
    • Inflammatory bowel disease and diabetes are predisposing factors
    • Bacteroides fragilis and E. coli are most common
    • Requires operative drainage
  • Muscle (pyomyositis):
    • Typically in the tropics
    • S. aureus is most common
  • IV drug abuse:
    • Staphylococcal species are most common
    • MRSA is common
    • May be sterile
  • Paronychia:
    • Infection around nail fold
    • Usually S. aureus
  • Felon:
    • Closed space abscess in distal pulp of finger
    • Usually S. aureus

Etiology

  • Abscess formation typically occurs due to a break in the skin, obstruction of sebaceous or sweats glands, or inflammation of hair follicles. The collection may be classified as bacterial or sterile:
  • Bacterial: Most abscesses are bacterial with the microbiology reflective of the microflora of the involved body part:
    • S. aureus is the most common causative organism
    • Community-acquired MRSA (CA-MRSA) common
  • Sterile: More associated with IV drug abuse and injection of chemical irritants
  • Risk factors for abscess formation:
    • Immunosuppression
    • Soft tissue trauma
    • Mammalian/human bites
    • Tissue ischemia
    • IV drug use
    • Chron's disease (perirectal)

Diagnosis

Signs and Symptoms

  • Local:
    • Erythema
    • Tenderness
    • Heat
    • Swelling
    • Fluctuance
    • May have surrounding cellulitis
    • Regional lymphadenopathy and lymphangitis may occur
  • Systemic:
    • Often absent
    • Patients with extensive soft tissue involvement, necrotizing fasciitis, or underlying bacteremia may present with signs of sepsis including:
      • Fever
      • Rigors
      • Hypotension
      • Altered mentation

History
  • Previous episodes: Raise concern for CA-MRSA
  • Immunosuppression
  • Medications:
    • Chronic steroids, chemotherapy
  • IVDU
  • History of mammalian bite

Physical Exam
  • Location and extent of infection
  • Presence of:
    • Associated cellulitis
    • Subcutaneous air
    • Deep structure involvement
  • Involvement of specialty area:
    • Perirectal
    • Hand
    • Face/neck

Essential Workup

  • History and physical exam
  • Gram stain unnecessary for simple abscesses in healthy patients
  • Wound cultures:
    • Not indicated in simple abscesses
    • May help guide therapy if systemic treatment is planned
    • May be useful in confirming CA-MRSA in patients with recurrent abscesses
    • May guide specific therapy in a compromised host, abscesses of the central face or hand, and treatment failures

Diagnostic Tests and Interpretation

Lab
  • Routine laboratory tests are not typically indicated.
  • Glucose determination may be useful if:
    • Underlying undiagnosed diabetes is a concern
    • There is a concern for associated DKA
  • For febrile patients who appear septic, systemically ill, or have recent IVDU the following labs are indicated:
    • Blood cultures
    • Lactate
    • Renal function
    • CK if myositis suspected

Imaging
  • Bedside US can be helpful in distinguishing cellulitis from abscess
  • CT/MRI can be helpful in determining deep tissue involvement
  • Plain films may reveal gas in tissue planes

Differential Diagnosis

  • Cellulitis
  • Necrotizing fasciitis
  • Aneurysm (especially with IV drug abusers)
  • Cysts
  • Hematoma

Treatment

Pre Hospital

Caution: Septic patients may require rapid transport with IV access and volume resuscitation.

Initial Stabilization/Therapy

Septic patient:
  • Immediate IV access
  • Oxygen
  • Crystalloid volume resuscitation
  • Blood cultures/lactate
  • Early antibiotic therapy—broad spectrum to include MRSA coverage.
  • Rapid source control (abscess drainage)
  • If patient remains hypotensive after volume resuscitation consider:
    • Central venous pressure monitoring
    • Mixed venous sampling

Ed Treatment/Procedures

  • Incision and drainage are the mainstays of treatment.
    • Incision should be deep enough to allow adequate drainage
    • Elliptical incision prevent early closure
    • Break loculations with gentle exploration
    • Irrigate cavity after expressing all pus
  • Loose packing of abscess cavity when:
    • Larger than 5 cm
    • Comorbid medical conditions
    • HIV
    • Diabetes
    • Malignancy
    • Chronic steroid use
    • Immunosuppressed
    • Abscess location: face, neck, scalp, hands/feet, perianal, perirectal, genital
    • Promote drainage and prevent premature closure
  • For simple cutaneous abscesses (<5 cm) packing may not be routinely indicated.
  • Routine antibiotics are not indicated.
  • Antibiotics are indicated for the following conditions:
    • Sepsis/systemic illness
    • Facial abscesses drained into the cavernous sinus
    • Concurrent cellulitis (see “Medication”)
    • Mammalian bites
    • Immunocompromised hosts
  • Perirectal abscess requires treatment in the operating room
  • Hand infections that may require surgical intervention:
    • Deep abscesses
    • Fight bite abscesses
    • Associated tenosynovitis/deep fascial plane infection
  • Loop drainage technique:
    • Less invasive
    • Simplifies wound care
    • Procedure:
      • Anesthetize locally
      • Incision made at outer margin of abscess
      • Use a hemostat to break loculations and manually express pus
      • Use hemostat to localize distal margin of abscess and use as guide for a second incision
      • Grasp silicone vessel loop with hemostat and pull through and then gently tie
      • Patient should move loop daily to promote drainage
      • No repeat ED visits generally required
      • Removal in 7–10 days is painless

Pediatric Considerations
Incision and drainage are painful procedures that often require procedural sedation and analgesia.

Medication

ALERT
  • Know your local susceptibility patterns
  • Oral antibiotics (moderate associated cellulitis):
    • Amoxicillin/clavulanate:
      • Use: Mammalian bites/MSSA/Streptococcus species
      • Adult dose: 500–875 mg (peds: 40–80 mg/kg/d div q12h) PO q12h
    • TMP-SMX:
      • Use: MRSA
      • Adult dose: 160/800 mg (peds: 4–5 mg/kg) PO BID
    • Clindamycin:
      • Use: MRSA
      • Adult dose: 300–450 mg (peds: 4–8 mg/kg) PO q6h
    • Doxycycline:
      • Use: MRSA
      • Adult dose: 100 mg (peds: over 8 yr: 1.1 mg/kg) PO q12h
    • Cephalexin:
      • Use: MSSA/Strep species
      • Adult dose: 250 mg PO q6h or 500 mg PO q12h (peds: 25–50 mg/kg/d div q12h)
    • Erythromycin:
      • Use: MSSA/Streptococcus species
      • Adult dose: 250–500 mg (peds: 10 mg/kg) PO q6–8h
  • IV antibiotics (systemic illness or extensive associated cellulitis):
    • Ampicillin/sulbactam
      • Uses: Human/mammalian bites and facial cellulitis
      • Adult dose: 1.5–3 g (peds: <40 kg, 75 mg/kg; ≥40 kg, adult dose) IV q6h (max = 12 g/d)
    • Vancomycin:
      • Use: MRSA
      • Adult dose: 15 mg/kg IV q12h (peds: 10–15 mg/kg/d div q6–8 h) (max. = 2,000 mg/d)
    • Daptomycin:
      • Use MRSA
      • Adult dose: 4 mg/kg IV q24h
    • Linezolid:
      • Use: MRSA
      • Adult dose: 600 mg IV/PO q12h (peds: 30 mg/kg/d div q8h)
    • Clindamycin:
      • Use: MRSA
      • Adult dose: 600 mg (peds: 10–15 mg/kg) IV q8h

Ongoing Care

Disposition

In accordance with abscess type and severity of infection

Admission Criteria
  • Sepsis/systemic illness
  • Immunocompromised host with moderate/large cellulitis
  • Perirectal involvement
  • Any abscess requiring incision and debridement in the operating room

Discharge Criteria
Most patients with uncomplicated abscesses can be treated with incision and drainage and close follow-up.

Follow-Up Recommendations

  • Recheck in 24–48 hr for packing removal and wound check.
  • Warm soaks for 2–3 days after packing removal

Pearls and Pitfalls

  • Consider CA-MRSA in recurrent abscesses
  • Pain control is essential during incision and drainage of abscesses
  • Beware of tenosynovitis and deep fascial space infections

Additional Reading

  • Alison DC, Miller T, Holtom P, et al. Microbiology of upper extremity soft tissue abscesses in injecting drug abusers. Clin Orth Related Res. 2007;461:9–13.
  • Buescher ES. Community-acquired methicillin-resistant Staphylococcus aureus in pediatrics. Curr Opin Pediatr. 2005;17:67–70.  [PMID:15659967]
  • Hankin A, Everett W. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med. 2007;50:49–51.  [PMID:17577944]
  • Ladd AP, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2012:45:1562–1566.
  • O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009;16:470–473.  [PMID:19388915]
  • Tayal V, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. J Acad Emer Med. 2006;13:384–388.
  • Tsoraides SS, Pearl RH, Stanfill AB, et al. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2012;45:606–609.

See Also

  • Bartholin Abscess
  • Bite, Animal
  • Cellulitis
  • CA-MRSA
  • Hand Infection
  • Mastitis
  • Paronychia

Codes

ICD-9

  • 566 Abscess of anal and rectal regions
  • 682.9 Cellulitis and abscess of unspecified sites
  • 685.0 Pilonidal cyst with abscess
  • 680.9 Carbuncle and furuncle of unspecified site
  • 705.83 Hidradenitis

ICD-10

  • Anal abscess
  • Cutaneous abscess, unspecified
  • Pilonidal cyst with abscess
  • Furuncle, unspecified
  • Carbuncle, unspecified
  • Cutaneous abscess, furuncle and carbuncle, unspecified
  • Hidradenitis suppurativa

SNOMED

  • 128477000 Abscess (disorder)
  • 200714005 Pilonidal sinus with abscess (disorder)
  • 82127005 perianal abscess (disorder)
  • 416675009 furuncle (disorder)
  • 416893007 Carbuncle (disorder)
  • 59393003 hidradenitis suppurativa (disorder)

Authors

Neal P. O’Connor


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