I&D Only or Add Antibiotics?

February 15, 2019

Written by Sam Parnell

Spoon Feed
Treating skin and soft tissue abscesses with antibiotics in addition to incision and drainage (I&D) resulted in significantly increased clinical cure rate (NNT = 14) and decreased incidence of new lesions (NNT = 10) compared to I&D alone.

Why does this matter?
Skin and soft tissue abscesses are a very common presenting complaint in the emergency department (ED) and outpatient clinics. For years, I&D was considered standard of care for simple abscesses, and the adjunctive use of systemic antibiotics was controversial. However, prior high-quality evidence for or against the use of systemic antibiotics in conjunction with I&D for abscess treatment was limited. Furthermore, abscesses due to MRSA have been increasing in prevalence, which could influence recurrence and treatment failure rate for abscesses after incision and drainage.

When in doubt, cut it out…and add antibiotics
This was a meta-analysis of four randomized controlled trials with a total of 2,406 participants comparing adjuvant antibiotics vs placebo in the treatment of abscesses after I&D. Studies were performed in the ED or outpatient clinics, and the antibiotics used were either trimethoprim-sulfamethoxazole or clindamycin. Almost half of abscesses were due to MRSA with prevalence of 49%.

Adjunctive antibiotic use reduced treatment failure (7.7% in antibiotic group vs 16.1% in placebo group, p=0.002) which corresponded to an odds ratio for clinical cure of 2.32, with NNT of 14 in favor of antibiotic use. In addition, there was decreased incidence of new lesions (6.2% in antibiotic group vs 15.3% in placebo group, p<0.001) with an odds ratio of 0.32 and NNT of 10. Adverse events occurred slightly more frequently in the antibiotic group (24.8% vs 22.2%, p=0.01), but most adverse events were mild and self-resolving consisting of gastrointestinal symptoms, rashes, drowsiness, or headache.

Another Spoonful
REBELEM also has a great summary on antibiotic use for abscesses: Reformation of an Antibiotic Nihilist

Source
Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019 Jan;73(1):8-16. doi: 10.1016/j.annemergmed.2018.02.011. Epub 2018 Mar 9.

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Reviewed by Clay Smith and Thomas Davis