Management of Cutaneous Abscesses by Dermatologists
February 2014 | Volume 13 | Issue 2 | Original Article | 119 | Copyright © 2014
Jason Chouake MD,a Aimee Krausz BA,b Brandon L. Adler BA,b Hillel W. Cohen PhD MPH,c
Joshua D. Nosanchuk MD,d,e and Adam Friedman MDb,f
aDepartment of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
bDivision of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
cDepartment of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
dDivision of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
eDepartment of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY
fDepartment of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, NY
IMPORTANCE: There is currently no data detailing the degree to which dermatologists follow CDC/Infectious Diseases Society of America
(IDSA) guidelines in the treatment of abscesses, which recommend that incision and drainage (I+D) as primary therapy for skin and
soft tissue infections (SSTI).
OBJECTIVE: To evaluate the management of skin abscesses by dermatologists.
DESIGN, SETTING, PARTICIPANTS: A national email survey of 780 dermatologists was conducted from May-June 2012. Awareness, experience, and preparedness of respondents for abscess treatment, as well as the treatment practices in different clinical scenarios were evaluated. Response rate = 65% (n=510). Eligibility criteria: board certified/eligible dermatologists practicing in US. Main practice affiliation: solo (20%), group (33%), university health system/academic (32%), multi-specialty (13%), and other (2%). Main practice setting: urban (49%), suburban (42%), and rural (9%).
MAIN OUTCOME and MEASURES: Practitioner report of: awareness of national guidelines, use of I+D in initial management of uncomplicated abscess found on face, trunk, and extremity on patients age 6 months, 3, 15, 50, and 80 years, and use of antibiotics in the initial management.
RESULTS: 99% of respondents were capable of performing I+D in their practice. The IDSA recommends cultures in all patients treated with antibiotic therapy, and does not recommend antibiotics for the treatment of simple abscess. 18% of respondents reported culturing abscesses less than 50% of the time, while 91% incorporated antibiotics into initial treatment. Nearly a quarter (24%) of respondents would choose an initial antibiotic that would not cover Methicillin-resistant Staphylococcus aureus (MRSA). For facial abscesses, as the age of the patient increased from infant, respondents were more likely to incorporate I+D into their initial treatment. For abscesses on the trunk and extremities, respondents were less likely to I+D infants and toddlers, compared to adolescents, adults and the elderly.
CONCLUSION: Although most dermatologists were prepared to manage uncomplicated abscesses (98%), this survey identifies gaps in clinical standards of care established by the CDC/IDSA. Identification of these practice gaps may impact physician practice and dermatology residency curricula, and may serve to improve abscess management and antibacterial stewardship in the outpatient setting.
J Drugs Dermatol. 2014;13(2):119-124.
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Skin and soft tissue infections (SSTIs) are generally uncomplicated at the time of initial presentation. However, these infections can worsen quickly when there are delays in presentation and treatment. When encountering these infections, physicians must respond quickly with an appropriate therapeutic plan.1 Physicians must also be aware of trends in microbial resistance, in order to optimize patient care.2
Staphylococcus aureus is the most frequent cause of skin and soft tissue infections in the United States.3 With the expanding prevalence of SSTIs caused by community associated methicillin resistant Staphylococcus aureus (CA-MRSA), the Centers for Disease Control and Prevention (CDC) have developed clinical care guidelines that emphasized the need to (a) consider MRSA in the differential diagnosis of all skin abscesses, (b) perform incision and drainage (I+D) of skin abscesses, and (c) to use culture results and antimicrobial sensitivity to guide antibiotic treatment.4 The Infectious Diseases Society of America recommends antibiotic treatment only after incision and drainage of an abscess when there is (a) severe of extensive disease, (b) signs and symptoms of systemic disease, (c) associated comorbidities of immunosuppression, (d) extremes in age, (e) abscess in an area difficult to drain completely (face, hand, genitalia), (f) associated septic phlebitis, (g) lack of response to incision and drainage alone.1 When antibiotic treatment is indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI), the IDSA recommends empiric coverage of CA- MRSA in the outpatient setting, pending culture results.1
Kemper et al, in a recent study5 surveyed a random sample of 385 general pediatricians to evaluate primary care pediatricians’ management of skin abscesses. In this study, respondents were less likely to I+D a 6-month-old when