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Abscess, Skin/Soft Tissue, Emergency Medicine


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

    • Chrons 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


Diagnosis Tests & 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


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

Medication


  • 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


Follow-Up


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.

  • Hankin  A, Everett  W. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med.  2007;50:49-51.

  • 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.

  • 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 (Topic, Algorithm, Electronic Media Element)


  • Bartholin Abscess

  • Bite, Animal

  • Cellulitis

  • CA-MRSA

  • Hand Infection

  • Mastitis

  • Paronychia


Codes


ICD9


  • 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


ICD10


  • K61.0 Anal abscess

  • L02.91 Cutaneous abscess, unspecified

  • L05.01 Pilonidal cyst with abscess

  • L02.92 Furuncle, unspecified

  • L02.93 Carbuncle, unspecified

  • L02.9 Cutaneous abscess, furuncle and carbuncle, unspecified

  • L73.2 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)

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