Most texts and guidelines suggest incision and drainage as the treatment for uncomplicated superficial cutaneous abscesses; however, there is no standard definition of the procedure and little evidence to support the additional steps involved. This survey is unique in that it evaluated previously unaddressed issues including use of pain control, irrigation, wound cultures, and packing. Significant variation exists with regard to the management of cutaneous abscesses. Our study attempted to describe variability in clinical practice to establish a basic understanding of the current management of emergency providers nationwide and compare management strategies to existing guidelines.
Incision and drainage has been considered to be one of the more painful procedures performed in the ED, second only to nasogastric tube insertion.12
Providing adequate pain management is a challenge, as the lower pH of the infected tissue reduces the effectiveness of local anesthetic. Our study demonstrated that most providers treat pain associated with I&D with local lidocaine and often with additional oral or intravenous narcotics. Although most references recommend at least local anesthesia, there is some discrepancy regarding the need for additional systemic pain management.4–10
The difference in abscess size, location, and patient’s pain threshold may account for this variability in practice. No randomized controlled trials to date have compared the effectiveness in pain reduction of these various techniques, and additional research in this area will likely yield improved patient care and satisfaction.
Irrigation, though recommended by most textbooks and cited guidelines,4–10
is routinely done by only about half of respondents. There is little consensus on the type and volume of fluid that should be used to irrigate the cavity. Although 1 single-site study found that physician assistants were less likely to use irrigation than attending physicians and residents, our study demonstrated the opposite.11
In fact, less than half of the physicians surveyed routinely used irrigation after I&D, compared with 84% of midlevel providers. This is possibly because of the additional time required to irrigate, the undesired effect of purulent discharge splashing under high pressure, and lack of evidence to support its routine use. No randomized controlled trials have investigated the theoretical benefit of reducing the bacterial load in abscesses through copious irrigation.
Most texts and guidelines recommend a wide incision and often cite insufficient drainage as the cause of treatment failure. Continuing the incision over the entire length of the abscess theoretically allows for adequate room to probe loculations, facilitates subsequent packing changes, and allows for adequate drainage. However, a recent study in a pediatric population calls this standard practice into question. In a study with 115 patients, using 2 small incisions (4–5 mm) far apart on the abscess and a loop drain tied on top of the skin, the success rate was 94.5%, as measured by need for additional intervention.13
Large incisions produce large scars, and cosmetic outcome may be an important factor for patient satisfaction. Although it has not been studied in ED patients, primary closure has been used in the operating room under general anesthesia and has been shown to reduce cost, reduce time for wound healing, and improve cosmetic appearance.14–16
Although no studies have compared outcome with incision type, needle aspiration alone is commonly associated with higher rates of treatment failure.17
Our study demonstrates that most providers use linear incisions and very few perform needle aspirations unless it is used diagnostically to determine if a lesion contains purulent discharge. Primary closure of abscess cavities was rarely reported.
The use of gentle packing is generally recommended by current guidelines to prevent premature wound closure and allow continuous drainage after I&D.9
However, the theory behind wound packing is based on consensus guidelines rather than evidence-based data and is performed at the discretion of the provider.18
Furthermore, a small pilot study challenged this mantra by demonstrating that packing may cause increased pain and is not associated with improved outcome.19
Our study demonstrated that almost all providers routinely used packing and frequent wound repacking visits despite the lack of supporting evidence and increased pain and inconvenience to the patient. Further randomized controlled trials are needed to determine the effects of packing on clinical outcomes.
Although the 2011 Infectious Diseases Society of America guidelines recommend wound cultures in certain circumstances, the routine use of wound cultures in uncomplicated abscesses in otherwise healthy individuals is often unnecessary in the ED.20
While the prevalence of MRSA is variable geographically, it has become the most common cause of skin and soft tissue infections and is often treated empirically. Our study reflects the fact that although most physicians do not routinely order wound cultures, many midlevel providers still attempt to identify an organism. Wound cultures are costly and results are neither available immediately nor likely to change management. Although cultures may be needed in some instances, it is unclear why this was more routine practice among midlevel providers.10
Perhaps the most surprising result of our study is that only 17% of providers indicated that they routinely give oral antibiotics after I&D. While this practice follows guidelines (Clinical Infectious Disease, Center of Disease Control), textbooks,4–10
and recommendations from recent studies,21,22
it is significantly less than the antibiotic use of 53% to 80% reported in previous studies.1,11
This survey suggests that physicians are perhaps now reserving the routine use of antibiotics for specific cases. Most providers stated that they would select antibiotics with MRSA coverage, but would not routinely prescribe them unless there were certain risk factors such as a history of MRSA, immunodeficiency, or surrounding cellulitis. The variability in the number and types of antibiotic coverage may be influenced by local susceptibilities and desire to cover both MRSA and other bacteria.
As we continue to improve our practice as emergency care providers and move toward more evidence-based care, many of these practices will likely be challenged, and perhaps what has been “standard” will be replaced by less invasive, less painful, and more effective treatment of even our most routine patient presentations.