Appropriate treatment for "abscess too small to drain"

[winterallsummer]

2nd yr PA-S here with a question for PA-C's.

 

Patient comes in c/o a "bump" on my ____ (take your pick) that has been there 2-3 days and is really, really painful.  On exam is a "non-fluctuant abscess" (as described to me by a preceptor) / evolving folliculitis.  No systemic sx, no cellulitis.  Pt had one of these before that was larger and was I&D'd.  

 

Pt was sent home on keflex and bactrim and advise to apply warm compress.  Is this appropriate?  Would these drugs even penetrate the abscess (my understanding is clinda does but only at high doses)?  Is it better to try to drain these with a needle or just send the pt home with instructions to return if worse?

[ventana]

no that is no appropriate

 

new report out is the 23,000 deaths a year from resistant bugs

 

we may well enter the POST ABX era where the bugs are all resistant

 

 

 

Lets go back to the basic's   Abscess needs to be drained to get better.......  it does NOT need ABX

 

I can honestly say I have very rarely seen anyone get horribly sick from a local small abscess (and those that did you could see it coming)

 

So what would I do? 

 

Nothing, tell them to go home and hot pack it..... and f/u with the PCP - who should be able to do a I&D in the office (if is a simple small one)

If they really want you do something... and I have done exactly this......  

Offer to do a NEEDLE I&D

 

Take an 18--21g needle and (after cleaning surface) stick it right in the middle of it .......  sill hurt and bleed, but it "allows the infection to escape" so to speak

 

 

make sure they are not on immune suppression ie chemo or steroids to be safe - but the healthy 18 year old who comes in with a red spot (I use the size of a quarter to help decide - < this is just hot packs ) gets the talk of hot packs and if they push a needle I&D

[EMEDPA]

agree with above. I do lots of "needle I+D's" with an 18 g needle on things which are basically pimples. I don't use anesthesia either as it hurts more than the quick stick with the 18g.

[polarbebe]

I was taught young patients with no comorbid conditions such as DM, chronic steroid use, HIV, etc do not require antibiotics with a well drained abscess (no systemic symptoms).

 

Sorry, misread original post... If too small to drain would agree with above posts.

 

In practice however, they are almost always given in the population I work with. I work in NYC, had the chief of surgery discuss abscesses (during our monthly ED meeting) that present to the ED and strongly recommend keflex and bactrim due to the high rates of MRSA in the local community. I would say it depends on your community, resistances, biograms. You can speak to ID, a clinical pharmacist about the bugs and resistances that are common in your community.

[skyblu]

No antibiotics for abscesses unless there is surrounding cellulitis or (in drain able ones) unsatisfactory drainage of it.

 

For a small one that is essentially a pimple, I unroof the pustule with 18g needle, discharge with hot compresses and close follow up with PCP.

 

I just learned a neat trick for hot compresses. Most people wet a washcloth with hot water, but this only stays truly hot for a minute or so. A colleague of mine told a patient to hard-boil an egg, wrap it (while still hot) in a washcloth, and hold it to the area. Holds heat a lot longer, and hey, built-in snack! (A heating pad works too, but they are large and hard to get good contact on some body parts.)