Download Soft Tissue Infections: Abscesses, Cellulitis and Necrotizing Fasciitis

Abscess Management in a
Post CA-MRSA era
Erin Marra MD
Simran Vahali MD
2016
Abscess Management
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What are current guidelines in abscess
management?
Do we I&D all abscesses or can we use
needle aspiration?
Do we need to pack all abscesses we
drain?
Who needs antibiotic treatment?
Is management different in pediatric cases?
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NEJM, 2006
Prospective prevalence study
N = 422
Patients with acute, purulent skin and soft
tissue infections
11 university affiliated EDs in August 2004
Cultures obtained on all patients
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S. aureus isolated from 320/422 pts (76%)
MRSA prevalence 59% (rest was MSSA)
Among the MRSA isolates
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95% susceptible to clindamycin
 6% susceptible to erythromycin
 60% susceptible to fluoroquinolones
 100% susceptible to rifampin and bactrim
 92% susceptible to tetracycline
Follow up by phone 2-3 weeks after enrollment
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Antibiotics discordant in 100/175 patients
MRSA most common cause of abscesses
presenting to the ED
Empiric antibiotics prescribed in the ED should
cover MRSA in patients with cutaneous
abscesses
MRSA IN INDIA?
Methicillin resistant staphylococcus aureus (MRSA) in India:
Prevalence & susceptibility pattern
Indian J Med Res. 2013 Feb; 137(2): 363-369
• Studied 15 Indian tertiary care centers during 2008-2009
• 26,310 isolates obtained
• Overall prevalence of MRSA= 41%
• 2009: 47% ICU; 49% ward; 27% community
• Mrjority of isolates from skin and soft tissue infections>
respiratory and blood infections
• Low susceptibility of MRSA to ciprofloxacin (21%)
Treatment options for MRSA
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Recommendations from authors
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Culture your wounds
Vancomycin and Linezolid for MRSA
De-escalate once culture sensitivities are
returned
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201 staph isolates detected as MRSA out
of 500 staph samples (40.2%)
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143 were HA-MRSA (71.1%)
58 were CA-MRSA (28.8%)
Suggestions by authors
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Ca-MRSA
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Had “relatively” low resistance patterns for
clindamycin (21%), bactrim (22%), gentamicin
(17%), tetracycline (14%), chloramphenicol (7%)
and amikacin (6%), nitrofurantoin (0%)
Ha-MRSA- use linezolid and Vancomycin
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Journal of Emergency Medicine, 2011
Literature review
MRSA - no reliable historical, physical or
epidemiological risk factors
Wound cultures - not necessary in
uncomplicated abscesses
Antibiotics - do not aid in healing but may
decrease rates of formation of new lesions
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Incision and drainage - primary treatment of
superficial abscesses
Packing - small pilot studies show similar
outcomes in packed and un-packed
abscesses
Wound Care Follow-up - 48 hour check
Abscess Incision and Drainage
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If I&D is considered primary treatment of
abscesses, what is role of needle
aspiration?
What to do when you hear - “Just go stick
a needle in it.”
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Annals of Emergency Medicine, 2011
Nonblinded randomized control trial
Pts with uncomplicated superficial abscesses
N = 101; I&D group (54) vs. ultrasound guided
needle aspiration (47)
Post procedure sono done for resolution
Pts had f/u at 48 hours and on day 7
Goal was sonographic resolution at day 2 and
clinical resolution at day 7
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60% needle aspirations yield little/no purulence
despite evidence of pocket on sono
Overall success needle aspiration 26% and I&D
80%
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Difference was 54% (95% CI 35-69%)
Both less successful with MRSA
Needle aspiration is insufficient therapy for skin
abscesses
To Pack or not to Pack
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Has packing drained abscesses been
shown to be of any benefit?
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Academy of Emergency Medicine, 2009
Prospective randomized single-blinded trial
Determine if packing of simple abscesses
after I&D has benefit over I&D alone
N = 48
Patients recorded pain scores BID
Follow up at 48 hours
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No significant differences in need for second
intervention at 48 hour f/u
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Packed group = greater pain scores immediately
post procedure (p = 0.014) and at 48 hours (p =
0.03)
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Packed = 23 - 4 required intervention
Nonpacked = 25 - 5 required intervention
p = 0.72; 95% CI 0.4-4.2
Greater use of ibuprofen (p = 0.12) and percocet (p = 0.03)
Not packing simple abscesses does not result in
increased morbidity
Antibiotics
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Are they indicated after I&D?
When should we be prescribing them?
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Annals of Emergency Medicine, 2007
Systematic Review Article
N = 6 RCTs, Prospective and Retrospective
Cohort Studies
Pts with I&D alone have same rates of resolution
as I&D + antibiotics
Both groups show > 90% full resolution
Current literature doesn’t support practice of
prescribing antibiotics after I&D of simple abscess
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Annals of Emergency Medicine, 2010
Multicenter, double-blind, randomized placebocontrolled trial
N = 190
Included pts > 16yr with uncomplicated abscess
In adults with soft tissue infection:
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Does bactrim reduce rate of tx failure by 15% relative to
placebo at 7 days after I&D?
What is the rate of new lesion formation within 30 days?
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All abscesses drained, packed, and had
wound cultures sent
Physicians and pts blinded
Pts returned at 2 and 7 days for re-eval
30 day f/u conducted over the phone
Rate of MRSA 53%
Pediatrics
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What are recommendations for abscess
management among the pediatric
population?
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Annals of Emergency Medicine, 2010
Double-blind, Randomized Controlled Trial
N = 161
Randomized to 10 days of bactrim or placebo
after I&D
Follow-up
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Visit or call at 10-14 days
Call at 90 days
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Primary outcome = treatment failure at 10d
Secondary outcome = new lesion at 10d or 90d
follow-ups
Non-inferiority of placebo compared to bactrim for
primary and secondary outcomes
Failure rates
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5.3% in placebo group
4.1% in antibiotic group
Noninferiority established (equivalence threshold of 7%)
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New lesions at 10d and 90d follow-up
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19 at 10d and 15 at 90d on placebo
9 at 10d and 13 at 90d on antibiotics
Statistically significant difference at 10d, not at 90d
Conclusion that antibiotics not required for pediatric
skin abscess resolution but may help prevent new
lesions in the short term
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Pediatric Infectious Disease, 2004
Prospective Observational Study
Determine if I&D alone is sufficient for
management of CA-MRSA abscess
N = 69
Initial visit and two follow up visits
Overall ID Guidelines
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What does Infectious Disease recommend
for MRSA management?
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Clinical Infectious Diseases, 2011
Management of SSTI in era of CA-MRSA
Cutaneous abscess
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I&D is primary treatment
For simple abscess I&D is likely adequate
Culture if use antibiotics, severe local infection, signs
of systemic infection, no response to initial treatment
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Antibiotics recommended for abscesses with:
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Recurrent or persistent abscesses
Associated comorbidities or immunosuppression
Severe or extensive disease
Rapid progression in presence of associated cellulitis
Signs/symptoms of systemic illness
Extremes of age
Abscess in area difficult to drain (face, hand, genitalia)
Associated septic phlebitis
Lack of response to I&D alone
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Empirical coverage of CA-MRSA in outpatients with SSTI
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Empirical coverage for b-hemolytic strep AND CA-MRSA
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Clindamycin, bactrim, tetracycline (doxy or minocycline),
linezolid
Clindamycin, bactrim, tetracycline plus b-lactam OR linezolid
alone
Pediatric considerations
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Cannot use tetracyclines in kids < 8 yoa
In hospitalized children vancomycin is recommended
Recurrent MRSA SSTI Management:
 Personal hygiene and good wound care
 Environmental hygiene measures
 Consider decolonizing
 Treat with antibiotics if active infection
 Treat symptomatic contacts
Take Home Points
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MRSA rates are high among adult and pediatric
patients presenting to the ED, and increasing in
India
I&D is primary treatment of abscesses
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Needle aspiration is not as effective
Packing may be painful and does not affect
outcome
No need to treat simple abscess with antibiotics
Take Home Points
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If you do treat with antibiotics, cover for MRSA
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Treat if recurrent, systemic illness, comorbidities, cellulitis
Questions?
References
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Duong, M., Markwell, S., Peter, J. and Barenkamp, S. (2010). Randomized, Controlled Trial of Antibiotics in the Management
of Community-Acquired Skin Abscesses in the Pediatric Patient. Annals of Emergency Medicine, 55, 401-407.
Edlich, R. F., Cross, C. L., Dahlstrom, J. J and Long, W. B. (2010). Modern Concepts of the Diagnosis and Treatment of
Necrotizing Fasciitis. Journal of Emergency Medicine, 39.2, 261-265.
Gaspari, R. J. et al (2011). A Randomized Controlled Trial of Incision and Drainage Versus Ultrasonographically Guided
Needle Aspiration for Skin Abscesses and the Effect of Methicillin-Resistant Staphylococcus aureus. Annals of Emergency
Medicine, 57, 483-491.
Hankin, A. (2007). Are Antibiotics Necessary After Incision and Drainage of a Cutaneous Abscess? Annals of Emergency
Medicine, 50, 49-51.
Lee, M. C. et al (2004). Management and outcome of children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatric Infectious Diseases, 23.2, 123-127.
Liu, C. et al (2011). Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of
Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Infectious Diseases, 52, 1-38.
Moran, G. J. et al (2006). Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department. New
England Journal of Medicine, 355, 666-674.
O’ Malley, G. F. et al (2009). Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary.
Academic Emergency Medicine, 16.5, 470-473.
Schmitz, G. R. (2011). How do you treat an abscess in the era of increased community-associated methicillin-resistant
staphylococcus aureus (MRSA)? Journal of Emergency Medicine, 41.3, 276-281.
Schmitz, G. R. et al (2010). Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin
Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection. Annals of
Emergency Medicine, 56, 283 – 287.