Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America
Note -the chart below forms some of the latest US thinking on treating Skin & Soft Tissue Infections. To help you understand the lingo -in brief -Purulent means ‘contains or consists of pus’ I&D = to Incision (cut) and Drain [an abscess] C&S = Culture and Sensitivity; Rx = treatment
Where Does Your Abscess Sit on the Table of SSTI’s?
Basically: For pus producing soft tissue infections (SSTIs) – The Mild Infection stage is thought of as needing just = incision and drainage; Moderate infection is someone with purulent infection with systemic signs of infection (fever etc) – should have abscess tested for culture and any antibiotic sensitivity/resistance; Severe infection is thought of as: patients who have failed incision and drainage plus oral antibiotics or those with systemic signs of infection such as temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/µL), or immunocompromised patients.
Nonpurulent SSTIs. Mild infection: typical cellulitis/erysipelas with no focus of purulence. Moderate infection: typical cellulitis/erysipelas with systemic signs of infection. Severe infection: patients who have failed oral antibiotic treatment or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction. Two newer agents, tedizolid and dalbavancin, are also effective agents in SSTIs, including those caused by methicillin-resistant Staphylococcus aureus,
If the abscess hasn’t been reabsorbed into the skin, it could need a bit of help to ensure the head continues to drain. You can gently push away the top of the abscess ‘lid’ with a sterile needle tip, and allow the abscess to drain. You can use a long sterile needle and roll the length of it across the top using a bit of downwards pressure, softly roll or push a bit downwards across the top area, allowing the pus and exudate to leak out. Use very clean, warm compresses to encourage more pus to LEAK, (not squeeze). Never squeeze, prod or poke or try and suck the pus out as you will spread the infection. You should see a hole and you should rinse with a gentle trickle of sterile saline solution (sterile salt water bought at any chemist or make your own).
- Put one cup of water and ½ teaspoon of salt into the pot. Put the lid on.
- Boil for 15 minutes with the lid on (set a timer).
- Set the pan aside until cooled to a room temperature.
- Carefully pour the salt and water (normal saline) from the pan into the jar or bottle and put the lid on, extract with a sterile syringe and use it as a gentle spray to clean the abscess inside.
The abscess can be covered with a bandage which should be checked daily, allowing for the fact that more pus may form and need to drain.
Note: This is for small areas of infection only. It is at this point that you should decide to go to a doctor if there is any sign of it getting worse by the day or hour. You will feel if it looks like it is getting better -any doubt will probably mean it is not healing and you must seek medical advice.
These days, the decision on whether to administer antibiotics against Staph. aureus, (the usual bacterium present in an abscess) as an adjunct to incision (cutting) and drainage should be made based on the presence or absence of systemic inflammatory response syndrome SIRS. This means if you feel any other signs such as fever, swelling of lymph areas such as groin or armpit areas, skin sloughing, fast heart beat, extreme pain, more pus, chills and feeling sick -it is urgent that you seek medical help. Your infection is in your system and is putting your immune system and bodily organs under pressure. Don’t delay.
MRSA – Interesting addition
I have included this part of a blog from http://jailmedicine.com as it provided an interesting discussion on some from our community and MRSA -in terms of repeated use of antibiotics and abscesses, definitely worth a read.
Second question–MRSA. MRSA infections are increasingly becoming resistant to the very few agents available to treat them, so I think it is especially important to apply the two rules to these infections.
- Don’t overprescribe. There is quite a lot of literature supporting the idea that you do NOT have to prescribe antibiotics following MRSA abscess I&D. The treatment for any abscess is adequate incision and drainage. You do not get any better resolution in most MRSA patients if you follow I&D with antibiotics.
- The Sledgehammer Rule. I think that it is seldom good practice to prescribe both Kelfex and Bactrim simultaneously. I know this is done outside of corrections, especially in ERs. The rationale is that without a formal culture, you are not 100% sure if this particular cellulitis is caused by methicillin resistant staph (resistant to Keflex, sensitive to Bactrim) or methicillin sensitive staph (resistant to Bactrim, sensitive to Keflex), and so, to cover all your bases, you prescribe both. However, personally, I think it is pretty easy to tell the difference between most cases of MRSA and non-MRSA infections just by looking at them. The MRSA organism is an abscess former, and so, even early on, MRSA infections tend to form an abscess or at least show a central “spider bite” core. Meth sensitive cellulitis usually does not have either. Make your best guess, maybe based on a picture the nurses send you if you are not right there, and re-evaluate as needed tomorrow or the next day. You will pick correctly 95% of the time.
Finally, what about those patients who get recurring MRSA abscesses? The patients who get recurring MRSA abscesses are typically MRSA carriers, and your goal then is to eradicate their carrier status. There are several ways to do this according to MRSA guidelines (such as these by the Infectious Disease Society of America)—here are three:
- Apply mupiricin (Bactroban) 2% ointment to both nostrils (where MRSA tends to hang out in carriers) twice a day for ten days.
- Chlorhexadine body wash once a day for 5 days.
- Rifampin 600 mg po BID for five days in addition to your primary MRSA drug, whether Bactrim or Doxycycline—don’t prescribe rifampin alone.
We are talking here about typical young healthy patients. Patients who have chronic health problems or are immunocompromised must be approached differently. The opinions here are my own. I could be wrong; feel free to disagree! (End of the Jailmedicine article)
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