Skin abscess: Difference between revisions

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*[[Ultrasound: Soft tissue|Soft tissue ultrasound]] can differentiate between [[abscess]] and cellulitis
*[[Ultrasound: Soft tissue|Soft tissue ultrasound]] can differentiate between [[abscess]] and cellulitis
**Assess for fluid collection and swirl within the collection
**Assess for fluid collection and swirl within the collection
**Recent small studies have shown limited utility to bedside ultrasound in this capacity as it rarely leads to change in management (i.e. when a provider feels there is an abscess present, ultrasound shows an abscess and when there is diagnostic uncertainty the ultrasound usually is unequivocal as well)<ref>Effect of initial bedside ultrasonography on emergency department skin and soft tissue infection management Mower WR, Crisp JG, Krishnadasan A, et al. Ann Emerg Med. 2019;74(3):372-380.</ref>


==Management==
==Management==
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**Pilonidal abscess
**Pilonidal abscess
**Abscess in an immunocompromised or diabetic patient
**Abscess in an immunocompromised or diabetic patient
*Alternative to packing is loop drainage technique with vessel ties<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref>, Penrose Drain, or you can cut the proximal cuff of a sterile glove<ref>[https://sinaiem.org/sterile-glove-used-as-a-drain-for-a-skin-abscess/ Sterile Glove Used As a Drain for a Skin Abscess? SinaiEM]</ref>
**Failure rate of 4.1% for loop vessel technique vs 9.8% for conventional packing. <ref>[http://www.ncbi.nlm.nih.gov/pubmed/28917436 Am J Emerg Med, 2018. Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis.] </ref>
**Other advantage is don’t have to keep coming back to the ER for painful repacking.
**Home Care (copied from Pediatric EM Morsels)<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref>
***Keep area clean.
***Can cover with gauze to absorb the residual drainage.
***Can shower and/or bathe.
**The loop drain can be removed when (copied from Pediatric EM Morsels)<ref>[https://pedemmorsels.com/incision-loop-drainage-abscess/ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels]</ref>
***Drainage has stopped.
***Cellulitis has improved.
***Usually is within 7-10 days.
*[[Antibiotics]]
*[[Antibiotics]]
**Although withholding antibiotics is part of [[Choosing wisely ACEP]], new evidence suggest antibiotic NNT of 14 to prevent 1 treatment failure<ref>Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.</ref>
**Although withholding antibiotics is part of [[Choosing wisely ACEP]], new evidence suggest antibiotic NNT of 14 to prevent 1 treatment failure<ref>Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.</ref>
**[[TMP/SMX]] x 5 days (all abscesses)<ref>[[EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess]]</ref>
**[[TMP/SMX]] DS BID x 5 days (all abscesses)<ref>[[EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess]]</ref>
**Consider more aggressive antibiotic treatment if concomitant [[cellulitis]]
**Consider more aggressive antibiotic treatment if concomitant [[cellulitis]]


Revision as of 08:14, 15 November 2020

Background

  • MRSA is the most common cause of purulent skin and soft-tissue infections.[1][2][3]

Clinical Features

  • Tender nodular region with surrounding induration
  • Fluctuance
  • Surrounding erythema

Differential Diagnosis

  • Cyst
  • Vascular malformation

Skin and Soft Tissue Infection

Look-A-Likes

Evaluation

Fluctulance on exam
Abscess on ultrasound
  • Clinical exam: fluctulance +/- erythema
  • Soft tissue ultrasound can differentiate between abscess and cellulitis
    • Assess for fluid collection and swirl within the collection
    • Recent small studies have shown limited utility to bedside ultrasound in this capacity as it rarely leads to change in management (i.e. when a provider feels there is an abscess present, ultrasound shows an abscess and when there is diagnostic uncertainty the ultrasound usually is unequivocal as well)[4]

Management

  • Incision and drainage
  • Packing
    • Abscess >5 cm in diameter
    • Pilonidal abscess
    • Abscess in an immunocompromised or diabetic patient
  • Alternative to packing is loop drainage technique with vessel ties[5], Penrose Drain, or you can cut the proximal cuff of a sterile glove[6]
    • Failure rate of 4.1% for loop vessel technique vs 9.8% for conventional packing. [7]
    • Other advantage is don’t have to keep coming back to the ER for painful repacking.
    • Home Care (copied from Pediatric EM Morsels)[8]
      • Keep area clean.
      • Can cover with gauze to absorb the residual drainage.
      • Can shower and/or bathe.
    • The loop drain can be removed when (copied from Pediatric EM Morsels)[9]
      • Drainage has stopped.
      • Cellulitis has improved.
      • Usually is within 7-10 days.
  • Antibiotics
    • Although withholding antibiotics is part of Choosing wisely ACEP, new evidence suggest antibiotic NNT of 14 to prevent 1 treatment failure[10]
    • TMP/SMX DS BID x 5 days (all abscesses)[11]
    • Consider more aggressive antibiotic treatment if concomitant cellulitis

Disposition

Admission

  • Reserved for significantly ill patients or those requiring surgical intervention

Discharge

  • Appropriate for majority of patients
    • Follow up in 2 days for wound check

See Also

External Links

References

  1. ↑ Maligner D et al. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department. N C Med J. 2008 Sep-Oct;69(5):351-4.
  2. ↑ Pickett A et al. Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department. Pediatr Emerg Care. 2009 Dec;25(12):831-4.
  3. ↑ Bradley W. Frazee et al. High Prevalence of Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin and Soft Tissue Infections http://dx.doi.org/10.1016/j.annemergmed.2004.10.011
  4. ↑ Effect of initial bedside ultrasonography on emergency department skin and soft tissue infection management Mower WR, Crisp JG, Krishnadasan A, et al. Ann Emerg Med. 2019;74(3):372-380.
  5. ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
  6. ↑ Sterile Glove Used As a Drain for a Skin Abscess? SinaiEM
  7. ↑ Am J Emerg Med, 2018. Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis.
  8. ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
  9. ↑ Incision and Loop Drainage of Abscess BY SEAN M. FOX Pediatric EM Morsels
  10. ↑ Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.
  11. ↑ EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess
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