Verify that there is not a more severe soft tissue infection such as necrotising fasciitis or sepsis complicating the abscess

• Cutaneous abscesses are common in the emergency department and incidence has increased, likely due to the emergence of community-associated methicillin resistant staphylococcus aureus (CA-MRSA) as a major pathogen.
• Depending on geographic location, up to 50% of cutaneous abscesses are caused by MRSA.
• Frequently, cutaneous abscesses are obvious on exam, but sometimes deep abscesses are not visible.
• Point of care ultrasound (POCUS) can aid in the diagnosis of deep abscesses.   This is important since the treatment of an abscess is incision and drainage (I and D). Therefore use POCUS in cases of cellulitis, particularly if the patient has risk factors for MRSA (prior MRSA infection, injection drug use, MSM, diabetes mellitus, hospital admission in prior 3 months).

Please see the ultrasound image of an abscess File:UOTW 66 – Ultrasound of the Week 1.webm – WikiProjectMed (mdwiki.org)

^{Attribution: Ben Smith, CC-BY-SA-4.0}

• In general, the treatment of abscesses is incision and drainage; antibiotics are not routinely needed  in absence of surrounding cellulitis.
  • However, in areas where the rates of CA-MRSA is high (>30%), treatment with a 7 day course of TMP-SMX is associated with higher cure rates.
  • Doxycycline is a reasonable alternative (5-7 days at 100 mg PO BID).  Sensitivity of CA-MRSA to TMP-SMX or doxycycline remains > 90%.
• Proper abscess drainage is important and the incision should be up to half of the width of the abscess (see video: Abscess Incision and Drainage : Emergency Care BC)
• Packing, while historically carried out, results in greater pain and has not been shown to improve outcomes.
• Culture and sensitivity of abscess drainage material is not essential, but useful to establish local  patterns of bacterial pathogens.

• Hospitalization for cutaneous abscesses is usually not required.

• Not generally required.

• Cutaneous abscesses in anatomically sensitive areas (face, perianal, perineal areas) may require referral. In some cases they may be associated with an underlying fistula.

• Most patients with cutaneous abscesses may be safely discharged home unless there are mitigating circumstances (social, etc).

1. Abscess (Boil) Patient Discharge Sheet https://emergencycarebc.ca/wp-content/uploads/2020/01/Abscess-1.pdf

   
   

1. Wilbur MB, Daum RS, Gold HS. CLINICAL DECISIONS. Skin Abscess. N Engl J Med. 2016 Mar 3;374(9):882-4. doi: 10.1056/NEJMclde1600286.

   
   

2. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016 Mar 3;374(9):823-32. doi: 10.1056/NEJMoa1507476.

   
   

3. Barbic D, Chenkin J, Cho DD, Jelic T, Scheuermeyer FX. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open. 2017 Jan 10;7(1):e013688. doi: 10.1136/bmjopen-2016-013688.

   
   

4. Stenstrom R, et al. Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department. CJEM. 2009 Sep;11(5):430-8.

   
   

5. Wilmer A, Lloyd-Smith E, Romney MG, Champagne S, Wong T, Zhang W, Stenstrom R, Hull MW. Reduction in community-onset methicillin-resistant Staphylococcus aureus rates in an urban Canadian hospital setting. Epidemiol Infect. 2014 Mar;142(3):463-7. doi: 10.1017/S0950268813001568. Epub 2013 Jun 28.