1. Abscess: Incision and Drainage
Jessica M. Craig, MSPAS, PA-C
Pediatric General Surgery
Texas Children’s Hospital
Special thanks to:
Celia Flores PA-C
Susannah Ferguson
Karen Hizon PA-C
Veronica Victorian PA-C

2. Objectives
Recognize clinical manifestations and differential diagnosis of cellulitis vs. abscess
Comprehend general management of abscess including antimicrobial therapy and operative indications
Discuss procedural approach to I&D of abscess
Outline importance of after care and patient education following abscess I&D

3. Skin and Soft Tissue Infection (SSTI)
Collections of pus/debris within the dermis and deeper skin tissues
Prior abrasion, bug bites, diaper rash, epidermal barrier breakdown
Inflammatory response
Most common manifestation is abscess
Third-highest, non-cardiac, surgical cost driver at TCH in 2011 behind ECMO and appendicitis
2 months- 3 years old
Operative treatment of skin and soft tissue infections is a significant area of resource utilization at our hospital. **It was actually the third- highest, non-cardiac, surgical cost driver at TCH in 2011, behind ECMO and appendicitis
Most common ages for pediatrics is 2mo-3 yrs in the diaper area
South Texas has one of the highest population of SSTIs in children

4. Diagnosis
CLINICAL!!!!
Physical examination: erythema, tenderness, pain, warmth, induration/ edema, fluctuance/ drainage
Rarely, US: assess for fluid collection
Only when diagnosis is equivocal
Do not routinely obtain blood cultures in children with SSTI
Most commonly present with a 1-2 day hx of “pimple” or “bug bite” that got progressively larger overnight
Patients are typically very tender at the site. Many times babies and small children can have deceiving presentation which prompts providers to attempt treatment with antibiotics alone. The area is erythematous and indurated however difficult to assess fluctuance…these kids usually require drainage! There is an abscess under all of that thick skin on the buttock. Drain it!
Some will present with prior drainage attempt, “poke and drain” but the “head” closes back and the abscess continues to worsen. ER/office drain attempts – not adequate pain control makes it difficult to adequately drain the cavity

5. Clinical Manifestations
Cellulitis
Skin erythema, edema, warmth
Abscess:
Painful, fluctuant, erythematous nodule +/- surrounding cellulitis
Fever
Active drainage
Mark cellulitic borders
Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016; 316:325.

6. Differential Diagnosis
Contact dermatitis
Thermal injuries
Insect bite, snake bites
Folliculitis
Hidradenitis suppurativa
Necrotizing fasciitis: erythematous, swollen, warm and exquisitely tender; pain out of proportion

7. Microbiology Cellulitis: Skin abscess:
Beta-hemolytic streptococci: group A streptococcus or S. pyogenes
Skin abscess:
S. aureus (MSSA or MRSA): up to 75% of cases
Among S aureus causing SSTI at TCH, approx 50% are MRSA causing SSTI, approx 17% are clinda- resistant
Among S aureus causing SSTI at TCH, approx 50% are MRSA causing SStI, approx 17% are clinda- resistant

8. Antibiotic Table Age restriction Dose and frequency
Trimethoprim (TMP) and Sulfamethoxazole (SMX)
Simple SSTI
Children < 2 months
Oral: 8-12 mg TMP/kg/DAY divided every 12h
MAX: 160mg TMP/dose
Doxycycline
Simple SSTI if suspect CA-MRSA
Children < 8 years
Oral: 2-4mg/kg/DAY divided every 12-24h;
MAX: 100 mg/day
Clindamycin
None
Oral: 5-10mg/kg/dose every 8h
IV: mg/kg/dose every 8h
Cephalexin
IV: mg/kg/DAY divided every 6h
Vancomycin (for suspected/ confirmed MRSA requiring IV therapy)
IV: 15 mg/kg/dose every 8h;
MAX: 1 g/dose

9. Clinical Algorithm

10. Clinical Algorithm

11. Drainable Collection? No: Admission vs. Discharge
Admission required?  Begin empiric IV abx therapy
Safe for discharge?  PO clindamycin, prevention education, f/up with PCP
Yes: OR vs Mobile Sedation
Empiric IV abx therapy
Admission criteria:
Systemic sx’s (fever, SIRS)
Rapidly expanding or large lesions
Age < 3 mos
Concern for inadequate drainage of larger abscess
Abscess location
Unable to tolerate PO abx
Significant pain
Failed tx with 48h of abx
f/up concerns

12. Incision and Drainage Operating Room Mobile Sedation
General anesthesia
Conscious moderate sedation
Pending OR availability
> 6 months
Comorbidities
Easily accessible abscess location
Location
No cardiopulmonary PMH
Age
In the past, all abscesses were either drained in the ER or in the operating room depending on the size and the location of the abscess. **In efforts to decrease resource utilization and expedite care, the use of our mobile sedation service (MSS) was implemented for this disease
The MSS is a dedicated conscious sedation team that provides moderate sedation for stable patients throughout the hospital.
Patients eligible for MSS drainage were 6 months of age or older, had no concerning cardiopulmonary disease, and an abscess location that was easily accessible.

13. Equipment/ Supplies Sterile gloves, surgical drape, multiple 4x4 gauze
Syringe and needle (25,27, or 30 gauge)
Culture swab
Eye protection: surgical mask with visor
Number 11 or 15 scalpel
Curved hemostats
Povidone- iodine solution
Vessel loop
Local anesthetic
Dressing of choice

14. Sedation and Analgesia
Local anesthesia (Bedside)
0.25% Marcaine
Children: ≤2.5 mg/kg
Plain: 2.5 mg/kg/dose not to exceed 175 mg/dose
With Epi: 225 mg/dose
One puncture inserted into dome of abscess with syringe parallel to skin and rotate to distribute circumferentially

15. Procedure Appropriately prep and drape patient using sterile procedure
Identify area of maximal fluctuance
Using an 11 or 15 blade scalpel make incision over point of max fluctuance (Langers lines)
Culture purulent fluid
Probe with curved hemostat to break up loculations
Vessel loop placement
Closure: secondary intention
Antibiotic therapy if indicated
Tetanus ppx if indicated
Point of entry for first incision is typically the “head” of the original lesion.
Use curved hemostat to gently break up the loculations without creating tracking
Make the second incision as far apart as possible from the initial incision, staying within the abscess cavity. Goal is to reach the opposite side of the abscess cavity to ensure adequate drainage. Using the hemostat to retrieve the vessel loop and pull through the subcutaneous tissue. **Do not create a cavity or tunnel.
Tie approximately 5 knots making sure the knots are secure. I clamp the vessel loop with my hemostat to tie down to that. Vessel loop should be somewhat loose to skin.

16. Vessel Loop
Placed intraoperatively, allows for continued passive drainage postoperatively
Vessel loop allows for continued drainage. No need to torture a baby/child/parent with packing for simple abscesses as these.
Vessel loops come in different sizes and colors. Sometimes require more than one

17. Complications
Recurrence
Bacteremia
Sepsis

18. Wound Care and Discharge Instructions
Sitz baths in warm, soapy water TID, warm compresses
Continue abx therapy, transition to PO
F/up in 7-10 days for wound check and f/up cultures
Vessel loop:
warm sitz baths TID, especially after BM to prevent contamination
Keep area clean and dry
F/up in 1 week in drain removal clinic- removed at bedside
Return/ ER precautions:
Fever/chills, re-accumulation of pus, increased pain or redness, swelling, streaking (!!!)

19. References
Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016; 316:325.
Adams, C. M., Neuman, M. I., & Levy, J. A. (2016). Point-of-care ultrasonography for the diagnosis of pediatric soft tissue infection. Journal of Pediatrics, 169, e1.
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious
Duong, M., Markwell, S., Peter, J., & Barenkamp, S. (2009). Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Annals of Emergency Medicine, 55(5),
Elliott, D. J., Zaoutis, T. E., Troxel, A. B., Loh, A., & Keren, R. (2009). Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. Pediatrics, 123(6), e
Lane, R. D., Sandweiss, D. R., & Corneli, H. M. (2014). Treatment of skin and soft tissue infections in a pediatric observation unit. Clinical Pediatrics, 53(5),
Diseases Society of America. Clin Infect Dis 2014; 59:e10.
Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med 2005; 12:601.
Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
Singer AJ, Talan DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039.
Abrahamian FM, Shroff SD. Use of routine wound cultures to evaluate cutaneous abscesses for community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2007; 50:66.
Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician 2007; 53:1680.
Leinwand M, Downing M, Slater D, et al. Incision and drainage of subcutaneous abscesses without the use of packing. J Pediatr Surg 2013; 48:1962.
Adams, C. M., Neuman, M. I., & Levy, J. A. (2016). Point- of-care ultrasonography for the diagnosis of pediatric soft tissue infection. Journal of Pediatrics, 169, e1.