Liz Daniels, an awesome senior Resident from Cincinnati Children’s was gracious enough to share her thoughts on two abscess questions that perplexed her during a recent stint in the ED.
Abscesses: Drain or not? Antibiotics or not?
Draining an abscess is a very common chief complaint in the ED, and accounts for more than 4 million ED visits annually (1), and typically, before arriving to the ED, the family has already seen the pediatrician who has deemed it “drainable”. However, sometimes it isn’t always so clear, and providers can disagree on the necessary management. Alternatively, patients are started on antibiotics for cellulitis appropriately, but the infection coalesces into an abscess and they come to the ED. One study showed the inter-rater reliability (weighted value) between physicians as to whether or not an “abscess” is worth draining was 0.43, suggesting that for patients with equivocal volumes it is hard to quantify what is worth draining (2). So then, if you have an equivocal infection that you think needs to be drained, how can you be more confident? Unnecessary drainage is of course painful, might require sedation and has risks. Just as a side note: large labial (>4cm) abscesses are more likely to require surgical drainage, so talk with attending about surgery before cutting. Also, needle aspiration is sometimes taught, but beware, the evidence shows higher failure rate with needle aspiration compared to classic I&D(3).
So how does one determine if there is at least 0.5 ml of fluid worth to drain? Bedside ultrasound is valuable and has been shown with the equivocal infections to help increase the sensitivity to 97% and specificity to 83% in pediatric abscesses (4). It’s definitely worthwhile since the tools are available at CCHMC-land.
Whether or not to prescribe antibiotics has been debated for a long time, and currently still has conflicting evidence. Drainage of the abscess alone is treatment. However, some providers do adjuvant therapy with antibiotics after drainage, and pediatricians in outpatient practice are more likely to do that (5). When doing so, ensure you’re covering for MRSA so choose Bactrim or clindamycin (good luck getting them to take it!!) Pro tip: clindamycin sprinkles (capsules opened) mixed with chocolate frosting is my favorite.
1) Factors influencing drainage setting and cost for cutaneous abscesses among pediatric patients. Chumpitazi CE, Rees CA, Camp EA, Valdez KL, Choi B, Chumpitazi BP, Pereira F. Am J Emerg Med. 2017 Feb;35(2):326-328. doi: 10.1016/j.ajem.2016.10.031. Epub 2016 Oct 17. PMID: 28029490
2) Reliability of clinical examinations for pediatric skin and soft-tissue infections. Marin JR, Bilker W, Lautenbach E, Alpern ER. Pediatrics. 2010 Nov;126(5):925-30. doi: 10.1542/peds.2010-1039. Epub 2010 Oct 25. PMID: 20974788
3) Skin and Soft Tissue Infections. Mistry, Rakesh D.. Pediatric Clinics of North America , October 2013, Vol. 60 Issue: 5 p1063-1082, 20p.
4)Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections. Subramaniam S, Bober J, Chao J, Zehtabchi S. Acad Emerg Med. 2016 Nov;23(11):1298-1306. doi: 10.1111/acem.13049. Epub 2016 Nov 1.. PMID: 27770490
5) Management of skin abscesses by primary care pediatricians. Kemper AR, Dolor RJ, Fowler VG Jr. Clin Pediatr (Phila). 2011 Jun;50(6):525-8. doi: 10.1177/0009922810394837. Epub 2011 Jan 23.PMID: 21262755