1.) Do you routinely pack abscesses after incision and drainage (I & D)? If so, what is your endpoint (i.e. when do you stop re-packing, and when do you stop ED follow-up)?
2.) Do you ever use primary closure after abscess I & D? What about loop drainage?
3.) Which patients do you treat with antibiotics after I & D?
4.) Which antibiotics do you select for treatment of abscesses after I & D? When do you consider sending wound cultures?
OK that is SUCH a gross picture for the topic!
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1) never pack, prolongs wound healing, worse aesthetic outcomes
2) I primary close abscesses <5 cm, provided no evidence of cellulitis. Never used loop drains. But think it's ok for larger abscesses that require some recurrent breakup of loculations.
3) those with surrounding erythema beyond the base of the fluctuance, those with proximal streaking, or fever. Or IVDA history.
4) bactrim. Occasionally keflex. Wound culture the immunocompromised (AIDS, old diabetics, those on TNF blockers, etc), those I'm on the fence about admitting/placing in obs, bite cellulitis, those on their second visit.
1) Never “pack”, occasionally a drain(wick) if big and I think it’s going to close over and re-accumulate (i.e. when not confident in primary expression and irrigation)
2) No primary closure. Intrigued by loop drains ever since Rob’s cast, but never tried.
3) Antibiotics for those with significant cellulitis (most common reason – most subjective and probably not justified cause), lymphangitis, fever, “immunocompromised”, or recurrent.
4) Crap shoot in our area as the ratio is ~50/50. “LLs” generally get bactrim, “nice people” generally get cephalexin. That is totally politically incorrect, but we still have a certain “demographic divide”. Because of the uncertainty in MSSA vs MRSA in our area, I still culture if giving antibiotics.
1. Pack only enough to allow drainage for all but small abscesses. Too much packing leaves large space; makes it tempting to repack on follow up visit.
2. No primary closure. Loop is interesting tried it once, but I am more old school.
3. Abx for cellulitis and immune compromised.
4. Bactrim / clinda for mrsa coverage, cephalosporin when below the belt and gnr may be likely. Culture when giving abx, or other worries – really no harm checking, but you should follow up your own – colleagues may misinterpret a cx result when unsure of clinical picture.
Todd L. Slesinger, MD, FACEP, FCCM, FCCP Sent from my iPhone
1)Packing? Do you also place salt on your patients’ open wounds? (See #2)
2) Loop Abscess drainage all the way. The loop is beloved by your staff, your patients, and consequently, by you! It will keep wound open and obviate need for packing. (I’m forever grateful, Rob Orman!)
3)Like the others – immunocompromise or and angry abscess, red all around.
4)2 DS Bactrim BID. Get it!