Skin abscess: Difference between revisions
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==Background==
==Background==
*Localized collection of pus surrounded by inflamed tissue, usually caused by bacterial infection
*[[MRSA]] is the most common cause of purulent skin and soft-tissue infections.<ref>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.</ref><ref>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.</ref><ref>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</ref>
*[[MRSA]] is the most common cause of purulent skin and soft-tissue infections.<ref>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.</ref><ref>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.</ref><ref>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</ref>
*Standard skin abscess are ''not'' typically due to [[spider bites]] and should not be diagnosed as such
===Terminology===
*Furuncles (i.e. boils) are skin abscesses caused by staphylococcal infection, which involve a hair follicle and surrounding tissue
*Carbuncles are clusters of furuncles connected subcutaneously, causing deeper suppuration and scarring.


==Clinical Features==
==Clinical Features==
*Fluctulance
[[File:Five day old Abscess.jpg|thumb|Fluctulance on exam]]
*Tender nodular region with surrounding induration
*Fluctuance with or without surrounding erythema


==Differential Diagnosis==
==Differential Diagnosis==
*Duct ectasia
*Cyst
*Cyst
*Vascular malformation
*Vascular malformation
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{{SSTI DDX}}
{{SSTI DDX}}


==Diagnosis==
==Evaluation==
===Work-up===
[[File:Isoechoic abscess.png|thumb|Abscess on ultrasound]]
*[[Ultrasound: Soft tissue|Ultrasound]] can be helpful
===Workup===
*'''Labs'''
**Not usually indicated
**Glucose may help identify undiagnosed diabetes, if suspected
**For febrile or systemically ill patients, obtain blood cultures, lactate, renal function, and CK
*'''Imaging'''
**[[Ultrasound: Soft tissue|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)<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>


===Evaluation===
===Diagnosis===
*Generally clinical diagnosis, may be assisted by ultrasound (above)
*Typically a clinical diagnosis, with or without use of bedside [[Ultrasound: Soft tissue|soft tissue ultrasound]] and/or [[I&D]] for confirmation


==Management==
==Management==
*[[Incision and drainage]]
*[[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<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<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:<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]]
**[[TMP/SMX]] x 5 days (all abscesses)<ref>EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess</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]] DS BID x 5 days<ref>[[EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess]]</ref>
***[[Clindamycin]] is as effective, but with higher adverse events<ref>Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. doi:10.1056/NEJMoa1607033</ref>
**Consider more aggressive antibiotic treatment if concomitant [[cellulitis]]
**Consider more aggressive antibiotic treatment if concomitant [[cellulitis]]


==Disposition==
==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==
==See Also==
[[Incision and drainage]]
*[[Incision and drainage]]
*[[Cellulitis]]
*[[Ultrasound: Soft tissue]]
 
==External Links==
==External Links==
*[https://www.merckmanuals.com/professional/infectious-diseases/biology-of-infectious-disease/abscesses?query=abscess| Merk Manual: Abscess]
*[http://emcrit.org/emnerd/case-pragmatic-wound/ EMNerd: Case of the Pragmatic Wound]
*[http://www.emlitofnote.com/2016/03/are-antibiotics-back-in-favor-for.html Are Antibiotics Back in Favor for Abscesses?]
*[http://www.sonoguide.com/abscess.html Sonoguide: Abscess Assessment]


==References==
==References==
<references/>
<references/>
[[Category:ID]]

Latest revision as of 13:42, 29 May 2022

Background

  • Localized collection of pus surrounded by inflamed tissue, usually caused by bacterial infection
  • MRSA is the most common cause of purulent skin and soft-tissue infections.[1][2][3]
  • Standard skin abscess are not typically due to spider bites and should not be diagnosed as such

Terminology

  • Furuncles (i.e. boils) are skin abscesses caused by staphylococcal infection, which involve a hair follicle and surrounding tissue
  • Carbuncles are clusters of furuncles connected subcutaneously, causing deeper suppuration and scarring.

Clinical Features

Fluctulance on exam
  • Tender nodular region with surrounding induration
  • Fluctuance with or without surrounding erythema

Differential Diagnosis

  • Duct ectasia
  • Cyst
  • Vascular malformation

Skin and Soft Tissue Infection

Look-A-Likes

Evaluation

Abscess on ultrasound

Workup

  • Labs
    • Not usually indicated
    • Glucose may help identify undiagnosed diabetes, if suspected
    • For febrile or systemically ill patients, obtain blood cultures, lactate, renal function, and CK
  • Imaging
    • 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]

Diagnosis

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[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:[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[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
  12. ↑ Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. doi:10.1056/NEJMoa1607033
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