Incision and Drainage Bucky Boaz, ARNP-C

Abscess EtiologyStaphylococcal strainsGroup A B-hemolytic streptoccalAnaerobic bacterial

PathogenesisABSCESS

Bacteriology of Cutaneous AbscessesHead, neck, extremities, trunkStaphlocciGroup a B-hemolytic streptococciButtocks and perirectalAnaerobesPerirectal area, head, fingers, and nailbedMixed aerobic and anerobic

Special ConsiderationsParental drug usersInsulin-dependent diabeticsHemodialysis patientsCancer patientsTransplant recipients

Laboratory FindingsOffer no specific guidelines for therapyNot indicatedGram stain not indicatedRoutine culture not indicatedExcept immunosuppressed

Indications and ContraindicationsIncision and drainage is definitive treatmentAntibiotics alone are ineffectivePremature incisionHeatNonsurgical recheck

Ancillary Antibiotic TherapyProphylactic AntibioticsEndocarditisBacteremia in other conditionsTherapeutic Antibiotics

Incision and Drainage ProcedureProcedure siteEquipment and AnesthesiaIncisionWound DissectionWound IrrigationPacking and Dressing

Follow-up CareReevaluation 1-3 days (48 hours standard)Closely followImmunosuppressedFacial abscessInstruct on wound careDecide on repackingPeroxide and Q-tips

Specific Abscess TherapyStaphyloccal DiseaseHidradenitis SuppurativaBreast AbscessBartholin Gland AbscessPilonidal AbscessInfected Sebaceous Cyst

Specific Abscess TherapyPerirectal AbscessPathophysiologyEpidemiologyPhysical and laboratory findingstreatment

Questions?

Cutaneous abscesses are among the soft tissue infections most frequently encountered in the emergency department (ED). Approximately 1 to 2% of patients presenting to the ED receive care for cutaneous abscesses. In contrast with most bacterial diseases, which are usually described in terms of their etiologic agent, cutaneous abscesses are best described in terms of their location. Localized pyogenic infections may develop in any region of the body and usually are initiated by a breakdown in the normal epidermal defense mechanisms, with subsequent tissue invasion by normal resident flora. Thus, an abscess is likely to be caused by the flora that are indigenous to that area. An exception is direct inoculation of extraneous organisms, such as infections that follow mammalian bites.

Staphylococcal strains, which are normally found on the skin, produce rapid necrosis, early suppuration, and localized infections with large amounts of creamy yellow pus. This is the presentation of a typical abscess. Group A beta-hemolytic streptococcal infections, on the other hand, tend to spread through tissues, causing a more generalized infection characterized by erythema and edema, a serous exudate, and little or no necrosis. This is the presentation of a typical cellulitis. Anaerobic bacteria proliferate in the oral and perineal regions; produce necrosis with profuse brownish, foul-smelling pus [3] ; and may cause both abscess and cellulitis. Normal skin is extremely resistant to bacterial invasion, and few organisms are capable of penetrating the intact epidermis. In the normal host with intact skin, the topical application of even very high concentrations of pathogenic bacteria does not result in infection. The requirements for infection include a high concentration of pathogenic organisms; occlusion, which prevents desquamation and normal drainage, creating a moist environment; adequate nutrients; and trauma to the corneal layer.

Infections in the soft tissue often begin as a cellulitis. Some organisms cause necrosis, liquefaction, and accumulation of leukocytes and debris, followed by loculation and walling off of pus, all of which result in the formation of 1 or more abscesses. There may be involvement of the lymph tissues, producing lymphangitis and subsequent bacteremia. As the process progresses, the area of liquefaction increases until it "points" and eventually ruptures into the area of least resistance Brook and Finegold studied the bacteriology of cutaneous abscesses in children. Their results closely correlate with those of Meislin and associates. Brook and Finegold found aerobes (staphylococci and group A beta-hemolytic streptococci) to be the most common isolates from abscesses of the head, neck, extremities, and trunk, with anaerobes predominating in abscesses of the buttocks and perirectal sites. Mixed aerobic and anaerobic flora were found in the perirectal area, head, fingers, and nailbed area. This study found an unexpectedly high incidence of anaerobes in nonperineal abscesses. Anaerobes were found primarily either in areas adjacent to mucosal membranes, where these organisms tend to thrive (e.g., the mouth), or in areas that are easily contaminated (e.g., by sucking fingers, which causes nailbed and finger infections or bite injuries). Parenteral drug users, insulin-dependent diabetics, hemodialysis patients, cancer patients, transplant recipients, and individuals with acute leukemias have an increased frequency of abscess formation compared with the general population. Local symptoms may not be the primary complaint, and the patient may present only with an exacerbation of the underlying disease process or an unexplained fever. These abscesses tend to have exotic or uncommon bacteriologic or fungal causes and typically respond poorly to therapy. The diabetic patient with diabetes-induced ketoacidosis should be evaluated extensively for an infectious process; a rectal examination should be included with the physical examination to rule out a perirectal abscess. This also holds true for other patients with abnormal cell-mediated immunity. The increased frequency of abscess formation in these patients and in the parenteral drug user is multifactorial. There may be intrinsic immune deficiencies in all these patients; they have an increased incidence of Staphylococcus carriage, and they have frequent needle punctures which allow access by pathogenic bacteria. It is important to note that a substantial percentage of abscesses in parenteral drug users are sterile and are the result of the injection of necrotizing chemical irritants. Drug users frequently use veins of the neck and the femoral areas, producing abscesses and other infectious complications at these sites. Any abscess near a vein of the antecubital fossa or dorsum of the hand should alert the physician to possible IV drug use; however, substance users may also inject directly into the skin ("skin popping"), causing cutaneous abscesses away from veins.The presence of a foreign body may serve as a nidus for abscess formation. A history of a possible foreign body at the site of an abscess should be sought. Because IV drug users frequently break needles off in skin toughened by multiple injections, the clinician should maintain a high index of suspicion for retained needle fragments. If an abscess is recurrent or if the patient is a known or suspected IV drug user, radiographs or other techniques should be considered to search for foreign bodies.Surgical incision and drainage is the definitive treatment of a soft tissue abscess. Antibiotics alone are ineffective in the face of a localized collection of pus. The drainage of a suppurative focus results in a marked improvement in symptoms and rapid resolution of the infection in uncomplicated cases. Premature incision before localization of pus will not be curative and theoretically may be deleterious, because extension of the infectious process and bacteremia from manipulation can result. In some cases the application of heat to an area of inflammation may ease pain, speed resolution of the cellulitis, and facilitate the localization and accumulation of pus. It must be stressed that nonsurgical methods are not a substitute for surgical drainage and should not be continued for >24 to 36 hours before the patient is reevaluated. Diagnostic needle aspiration is recommended if one is unsure of pus localization. The use of antibiotics remains controversial for both prophylaxis and treatment of cutaneous abscesses. As an overview, there are no data that definitively demonstrate the need for antibiotic therapy in conjunction with incision and drainage of uncomplicated cutaneous abscesses in healthy, immunocompetent patients without valvular heart disease. Prophylaxis for EndocarditisThe precise risk for endocarditis following incision and drainage of cutaneous abscess is unknown, and it is impossible to predict which patients will develop this infection or which particular procedure will be responsible. However, since bacteremia clearly occurs with manipulation of infected tissue, it is generally agreed that those patients at risk for cardiac complications related to transient bacteremia should be treated with appropriate antibiotics within the hour preceding the procedure. The transient bacteremia secondary to abscess drainage is probably of no concern in otherwise healthy, immunocompetent individuals without valvular heart disease. In contrast to patients with endocarditis risks, immunocompromised patients are at risk for developing septicemia secondary to a brief bacteremia.

Staphylococcal DiseasesThe Staphylococcus bacterium is a ubiquitous pathogen that frequently colonizes the nose, skin, perineum, and gut. It grows on the skin and thrives particularly well in hair follicles, causing boils (furuncles), wound infections, and occasionally carbuncles. Hidradenitis SuppurativaHidradenitis suppurativa (Greek hidros = sweat, aden = gland) is a chronic, relapsing, inflammatory disease process affecting the apocrine gland that primarily involves the axilla, the inguinal region, or both. The condition results from occlusion of the apocrine ducts by keratinous debris, which leads to ductal dilation, inflammation, and rupture into the SQ area. Secondary bacterial infection ensues, leading to abscess formation and scarring. Peripherally located abscesses are most commonly caused by Staphylococcus and respond well to traditional conservative incision and drainage. [Superficial abscesses in the SQ tissue may be drained under local anesthesia by means of an incision that radiates from the nipple.Periareolar abscesses exhibit a more troublesome profile. A retromammary abscess lies in the undersurface of the breast between the breast and the chest wall. Fluctuance may be difficult to appreciate because of the depth of the infection. Drainage under general anesthesia is required. Bartholin Gland AbscessThe Bartholin glands (vestibular glands) are secretory organs located at the 5 and 7 o'clock positions on each side of the vestibule of the vagina. Such patients present with swollen and tender labia and a fluctuant, grape-sized mass that may be palpated between the thumb and the index finger. It is preferable to make the drainage incision on the mucosal surface rather than on the skin surface. The incision is made over the medial surface of the introitus on a line parallel to the posterior margin of the hymenal ring. The abscess cavity is slightly deeper than most cutaneous abscesses, and one must be certain to enter the actual abscess cavity to achieve complete drainage The patient with a pilonidal abscess will seek care for back pain and local tenderness. On physical examination the area is indurated, but frank abscess formation may not be appreciated. One will usually see barely perceptible dimples or tiny openings at the rostral end of the gluteal crease. Treatment of the acutely infected cyst is the same as previously discussed for any fluctuant abscess; all hair and pus should be removed, and the lesion should be packed. Antibiotic therapy is not usually required Perirectal AbscessesPerirectal infections can range from minor irritations to fatal illnesses. Successful management depends on early recognition of the disease process and adequate surgical therapy. Because of the morbidity and mortality associated with inadequate treatment of these conditions, patients with all but the most localized abscesses should be promptly admitted to the hospital for evaluation and treatment under general or spinal anesthesia. It is believed that most perirectal infections begin in the intersphincteric space secondary to blockage and subsequent infection of the anal glands. Normal host defense mechanisms then break down, followed by invasion and overgrowth by bowel flora. EpidemiologyAnorectal abscesses occur most commonly in healthy adults and are more frequent in males (>2:1 ratio). These abscesses commonly appear during the fourth decade of life. Possible predisposing medical conditions are diabetes mellitus, inflammatory bowel disease, and other immunocompromised states. Physical and Laboratory FindingsThe diagnosis of a perianal abscess is generally not difficult. The throbbing pain in the perianal region is acute and is aggravated by sitting, coughing, sneezing, and straining. There is swelling, induration, and tenderness, and a small area of cellulitis is present in proximity to the anus. Rectal examination of the patient with a perianal abscess reveals that most of the tenderness and induration is below the level of the anal ring. Laboratory findings usually do not aid in the diagnosis. TreatmentSuccessful management of perirectal abscesses depends on adequate surgical drainage. Complications from these infections may necessitate multiple surgical procedures, prolong hospital stay, and result in sepsis and death.