by David Gude, MD
Four thousand and forty two pockets
of pus drained in 2007. Now
that’s a lot of spider bites. This
is the history most frequently invoked
by patients in an attempt to explain
their boils.
Fortunately, these cases are spread
across 10 locations, so no one clinic
location or doctor is drowning in pus.
However, with that many procedures
involving 60 physicians, it has been
necessary to adopt an internal standard
of practice so that both patients and
physicians know what to expect at follow-up and through the entire course
of treatment. Our experience is based
largely on the routine traditional
approach to an abscess, but we have
learned a lot over the years, and this
article is intended to share that experience
with the local medical community.
The primary approach to treating an
abscess caused by Methcillin Resistant
Staph Aureous (MRSA) or any other
source is incision and drainage.
Use of antibiotics alone is insufficient.
We perform a generous field block, with a
lidocaine and Marcaine mixture, usually
at least 10 cc. Believe it or not, incision
and drainage of an abscess does
not have to hurt.
Then we make an incision, the
diameter of which is equal to, or slightly
greater than, the area of induration
(word of advice: do not depend on
fluctuance, as there is generally so
much inflammation that the area is too
firm to palpate a precise spot to determine
where a sac of fluid is contained).
We then use blunt dissection, i.e.,
gloved finger, cotton-tipped applicator,
or scalpel handle, to break down any
loculations in the cavity.
Once this is accomplished, all the purulent necrotic
material is expressed using manual
pressure. Then we perform irrigation or
additional cleaning. Finally, the resulting
cavity is packed with Iodoform
impregnated gauze.
Follow-up is in 48 hours, at which
time the packing is removed. In most
cases, the cavity has produced no further
pus, and the patient may begin
self-care at home, with a second follow-up 48 hours later.
In some instances, if additional pus has accumulated
or the abscess has been discovered
to extend, either repacking or
extension of the drainage by repeat
I & D is performed.
Home care consists of the patient
washing the area three times daily
using running tap water from a shower,
sink or tub. A dry dressing is applied,
and the cavity will typically close in
three weeks.
At times, it is necessary to
make a smaller incision for drainage,
most often in consideration of cosmetic
results, such as when the abscess is
on the face.
The difficulty with smaller
incisions is that these wounds may
require re-packing on more than one
occasion, a procedure most patients or
their families are unable to perform.
This then requires more frequent re-visits
to the clinic for wound care, which
can become burdensome for patients.
In the majority of cases where an I & D
is performed, we continue to obtain
Culture and Sensitivities, though these
are overwhelmingly MRSA. This super
bug remains sensitive to the bacteriostatic
drug, Trim-Sulfa. However, current
recommendations(1) are for two doublestrength
Trim-Sulfa, rather than the
usual single tablet.
In an effort to adhere to an evidencebased
medicine approach, we have
reviewed the available literature regarding
the use of antibiotics following an
I & D. The literature suggests, if the induration
is smaller than 5 cm and the
patient is afebrile, then antibiotics are
not advised(2).
However, it is often difficult
for physicians to resist prescribing
an antibiotic in the face of what is clearly
a bacterial infection. Thus, compliance
with this particular evidence-based
medicine recommendation among our
physicians is inconsistent.
The final weapon in our armamentarium
of treating this new epidemic has
been the creation of “Procedure
Rooms.” These rooms are primarily
dedicated to draining pus and addressing
other potentially infectious processes.
Specifically, non-infected wounds,
wound closures, and other procedures
are performed in this dedicated room.
All supplies within the Procedure Room
are used exclusively in that room.
Supplies can enter that room, but leave
only via waste disposal. The room is
decontaminated after each procedure.
No one really enjoys dealing with
pus. However, by using proper anesthesia,
aggressively opening the wound,
cleaning out the necrotic debri, packing
it open, and appropriately following
up on the procedure, we have
relieved a lot of suffering (4,042 times
in 2007).
We have also saved a few
thousand trips to the ED, and, who
knows, maybe even saved a few lives
with early intervention.
There is a silver lining in this plague.
Our physicians have found they are
more readily able to dissuade a patient’s
ardent desire for an antibiotic (when
they obviously have a viral respiratory
infection) by a frank discussion of the
consequences of antibiotic over-prescribing
and overuse, most notably, MRSA.
David Gude, MD is a
graduate of UTHSCSA,
where he also did his
training in Family
Practice. He has practiced
Urgent Care and
Occupational Medicine
with Texas MedClinic
for 24 years, and is the Chief Operating
Officer. He divides his time 40/60 between
clinical and administrative responsibilities.
__________________________________
1 The Sanford Guide to Antimicrobial
Therapy 2007, p. 47.
2 NEJM 355:666, 2006.
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