SURGICAL INFECTIONS

Volume 19, Number 3, 2018

ª Mary Ann Liebert, Inc.
DOI: 10.1089/sur.2017.225

Comparative Study of Drainage and Antibiotics

versus Drainage Only in the Management
of Primary Subcutaneous Abscesses

Julio López,1 Gilberto Gómez,1 Karime Rodriguez,2 Julio Dávila,3 José Núñez,2 and Luis Anaya1
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Abstract

Background: Skin and soft tissue infections are common problems dealt with in emergency departments and
medical offices. It is routine practice to prescribe antibiotic agents after incision and drainage of cutaneous
abscesses. However, current evidence does not support prescribing oral antibiotic agents after surgical de-
bridement. The aim of the present study was to determine the actual role of antibiotic agents after drainage of
cutaneous abscesses.
Patients and Methods: This was a prospective study of patients undergoing incision and drainage (I&D) of a
subcutaneous abscess. Patients were randomly assigned either to receive antibiotic agents (group 1) or placebo
(group 2) after I&D. The primary end point was resolution rate of the abscess at the seventh day. Secondary end
points were pain at the seventh day and total time to full healing of the wound. P value <0.05 was considered
statistically significant.
Results: One hundred sixty-five patients were included for analysis. Age, gender, body mass index (BMI), and
comorbidities did not differ substantially between groups. Chest and peri-anal abscesses were statistically more
frequent in group 2, whereas neck abscesses were more frequent in group 1 (p = 0.02). Leukocyte count was also
statistically higher in group 1 (p = 0.005). Resolution rate was 96% in group 1 and 93% in group 2, with no
statistical difference between both (p = 0.28). Neither pain at seventh day nor time to full healing differed
statistically between groups.
Conclusions: Antibiotic agents are not necessary for uncomplicated subcutaneous abscesses after I&D. These
cases can be managed safely on an outpatient basis without any increase in morbidity.

Keywords: antibiotic agents; cutaneous abscess; incision and drainage; skin abscess; soft tissue infection

S kin and soft tissue infections (SSTIs) represent

common problems dealt with in places such as emer-
gency departments and medical offices [1–3]. These types
of infections encompass a broad range of severity, ranging
from impetigo to invasive gangrenous infections, also known
as necrotizing fasciitis [4]. In the United States, cutaneous
cellulitis or abscess constitute the second most common
type of infection and result in approximately 600,000 hos-
pital admissions per year [5].
Most SSTIs result from infections with gram-positive cocci,
particularly Staphylococcus aureus and group A streptococci
[6–8]. Despite these bacteria being typical skin flora, they can
cause infections when a disruption of the skin barrier has
occurred. Gram-negative bacilli can also infect the skin and
soft tissues, most often in gluteal and axillary regions [9].
Anaerobic bacteria typically are absent in cases of cellulitis.
They are, however, responsible for severe cases of necro-
tizing fasciitis, in which they act as co-infecting organisms in
conjunction with Staphylococcus aureus or group A strep-
tococci [4–10].
It is common practice to prescribe antibiotic agents after
incision and drainage (I&D) of cutaneous abscesses. How-
ever, current evidence suggests that there is no actual benefit
of such practice and does not support prescribing oral anti-
biotic agents after surgical debridement [11]. Moreover, this
raises the question as to whether antibiotic abuse or misuse in

1
Department of Surgery, 2Emergency Department, Mexican Institute of Social Security, Delicias, Mexico.
3
Department of Surgery, Mexican Institute of Social Security, Chihuahua, Mexico.

345
 346
this setting might promote bacterial resistance. Perhaps a
large, rigorous, and randomized clinical trial might be able to
demonstrate that this practice causes more harm than benefit
to patients. Even so, many authors continue to recommend the
routine use of ‘‘simple’’ empiric antibiotic agents based on the
most probable organisms causing SSTIs [12]. Empiric anti-
biotic coverage may be warranted in patients who are severely
immunocompromised, those having a large area of cellulitis,
lymphangitis, or those exhibiting signs and symptoms of sys-
temic toxicity [13]
Patients and Methods
The study was conducted from November 2014 through
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May 2016 at General Zone Hospital (HGZ) No. 11 of the
Mexican Institute of Social Security in Delicias, Mexico
when authorization by the Local Ethical and Health Research
Committee was granted. The study complied with the poli-
cies of Mexico’s General Law of Health Research, as well
as the Declaration of Helsinki, and written informed consent
was obtained from all participants or legal representatives.
Eligible patients included only those older than 15 years
affiliated with the institute, who were diagnosed with sub-
cutaneous abscess and had not received antibiotic agents by
any route in the recent past (up to 15 days prior) to I&D.
Patients with history of malignancy, hematologic diseases,
human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS), splenectomy, necrotizing fasciitis,
Fournier gangrene, diabetic foot, toxic shock syndrome,
extensive cellulitis 5 cm or more, abscesses with peritoneal
fistulization, bone/joint involvement, severe circulatory
insufficiency, and patients likely to die in the short term
were excluded.
Study design
In this single-blinded, randomized, placebo-controlled
study, the patients admitted in the emergency department of
HGZ No. 11 with a diagnosis of subcutaneous abscess were
randomly assigned to receive or not to receive oral antibio-
tic treatment after undergoing I&D. Two study arms were de-
signed as follows. Patients in group 1 (study group) were given
analgesics and antibiotic treatment after I&D, whereas patients
in group 2 (control) received analgesics and placebo. Analgesic
treatment was provided by dipyrone 1 g and acetaminophen 1 g
orally three times a day, as needed. Antibiotic coverage with
ciprofloxacin 250 mg orally twice daily for 7 days was given
to patients in group 1. Placebo pills were also prescribed every
12 hours for 7 days.
All medications were previously stored in plain bottles
labeled as ‘‘Analgesic 1,’’ ‘‘Analgesic 2,’’ ‘‘Antibiotic 1, and
‘‘Antibiotic 2,’’ with the latter being the placebo pills. All
patients were discharged immediately after I&D and follow-
up visits were scheduled at 7, 14, and 21 days in the outpatient
clinic. Patients were instructed to return to the emergency
department as soon if they noticed continued signs and
symptoms of ongoing infection after 48 hours of their initial
treatment. Such signs and symptoms included malaise, in-
tense local pain and hyperthermia, fever, induration, and
redness (i.e., ongoing cellulitis). In such cases, the patients
were admitted to the surgical ward and received broad-
spectrum antibiotic agents until culture/antibiogram results
were available to adjust to the specific drugs.
LÓPEZ ET AL.
Randomization
After providing written informed consent, patients were
randomly assigned to one group by means of closed enve-
lopes in blocks of 10. The process was done by one of the
researchers in all cases.
Data collection
Data were obtained prospectively and recorded, and in-
cluded demographic information (age, gender, BMI, and
comorbid conditions), volume of abscess cavity, resolution of
the abscess at the seventh day, pain at the seventh day, and
time to complete healing.
Surgical procedure
Abscess sites were prepped with iodine povacrylex (0.7%
available iodine) and isopropyl alcohol, 74% w/w (Dur-
aPrep; 3M, St. Paul MN) or 0.8% iodopovidone (GER-
MISIN Espuma; Farmacéuticos Altamirano de México S.A.
De C.V., Ciudad De Mexico, Mexico), as available. Local
anesthesia was achieved using 2% xylocaine, and a skin in-
cision was made with a scalpel blade number 21 over a length
of at least half the diameter of the abscess as estimated clini-
cally. The incision was deepened as necessary to access the
abscess cavity. The content was then evacuated completely
and the cavity debrided thoroughly with several iodopovidone-
soaked gauze pads. Next, the volume of the abscess cavity was
estimated by infusing normal saline until the cavity was full.
Finally, the incision was packed with gauze soaked in 0.5%
hypochlorite solution and draped. Dressing changes twice
daily were prescribed during the first seven days, with re-
packing of the incision as described. On the first follow-up
visit, dressing changes were modified to once per day if an
appropriately granulated incision bed was observed.
Study end points
The primary end point was the rate of resolution of the abscess
at the seventh day (first follow-up visit) in the two randomized
groups. Resolution of abscess was defined as the presence of
three or more of the following criteria: no local hyperthermia;
no redness; no induration; and adequate granulation on incision
bed. Resolution or failure to resolve at the seventh day was
determined by a non-blinded researcher. Secondary end points
were local pain on the seventh day and time to complete healing.
Local pain was evaluated by means of the visual analogue scale
(VAS). Time to complete healing was defined as the time
elapsed from I&D to full epithelialization of the incision.
Statistical analysis
An analysis with intention-to-treat was done. Normality of
data distribution was first determined by Kolmogorov-Smirnov
test. In normally distributed data, continuous variables appear
as mean – standard deviation (SD), and were analyzed for
homogeneity by using unpaired samples t-test, whereas non-
normal continuous data are expressed as median – interquartile
range (IQR) and were tested for differences between two
groups by Mann-Whitney U test. Categorical variables are
expressed as N with percentage and were tested with w2 or
Fisher exact test, as appropriate. Statistical significance was
defined as p < 0.05. Statistical analyses were performed
using SPSS 20.0 for OSX (IBM SPSS Inc., Armonk, NY).
 ABSCESS MANAGEMENT 347

Results HIV/AIDS (n = 2), Fournier gangrene (n = 4); necrotizing

From November 2014 through May 2016, 280 patients
were admitted to the emergency department because of a
diagnosis of subcutaneous abscess. Of these, 86 patients were
excluded before randomization for the following reasons: age
15 years or younger (n = 5); ongoing malignancy (n = 6);
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fasciitis (n = 3); diabetic foot (n = 43); wound abscess plus
evisceration (n = 2); or refused to participate (n = 21). The
remaining 194 patients were randomly assigned to I&D plus
antibiotic (group 1; n = 101) or I&D plus placebo (group 2;
n = 97). In group 1, one patient was subsequently excluded

FIG. 1. Flow diagram of patient selection. HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome.
 348 LÓPEZ ET AL.

because no pus was evacuated after I&D (i.e., cellulitis
without abscess), whereas in group 2, three patients were
excluded for the same reason. Furthermore, seven patients
were subsequently excluded in group 1 and five patients in
group 2 because they took additional non-prescribed medi-
cations in the forms of pills, creams, ointments, or dry
powders in the recent past prior to their abscess treatment.
Thirteen patients did not attend the outpatient clinic for
follow-up revision. A total of 165 patients remained suitable
for outcome analysis (Fig. 1).
Patient characteristics
Patient demographics, peri-operative data, and abscess
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study group (group 1, n = 84; group 2, n = 81). Other demo-
graphic and peri-operative data such as age, gender, BMI,
comorbidities, and volume of the abscess were also compa-
rable between both groups (Table 1).
There was, however, statistically significant differences
with regard to abscess location (p = 0.02). Post hoc testing
revealed that chest and peri-anal abscesses were statistically
more frequent in the placebo arm, whereas neck abscesses
were more frequent in the antibiotic group. Leukocyte count
also was found to be higher in patients assigned to group 1
after I&D (p = 0.005).
End points

characteristics are shown in Table 1. No difference was ob- Resolution rates of the infectious/inflammatory process
served regarding the number of patients allocated to each were not statistically different when testing both study arms
(p = 0.28). Resolution rate in group 1 was 96% (n = 81),
Table 1. Characteristics of Enrolled Patients whereas it was 93% (n = 75) in group 2 (placebo). Overall,
Group 1 Group 2 seven patients returned to the emergency department for
Characteristic (antibiotic) (placebo) p revision after 48 hours because they noticed no improve-
ment of the incision. After a thorough examination, no
N 84 81 signs of ongoing infection or worsening were found in any
Age (y) 0.7a of these patients, who were reassured and encouraged to
Mean – SD 49 – 17 48 – 14 continue with the treatment.
Range 19–91 21–73 Assessment of pain by VAS revealed no statistical dif-
Gender 0.36b ference at the seventh day, nor did the time to full healing of
Male 46 (55%) 50 (62%) the incision (Table 2). Eighty-eight percent of patients in
Female 38 (45%) 31 (38%) group 1 and 90% of patients in group 2 achieved full epi-
BMI (kg/m2) 0.55a thelialization by the 21-day follow-up visit.
Mean – SD 30 – 5 29 – 5
Range 21.8–43.6 20.5–53.3 Discussion
Comorbidities 0.67b
DM2 10 (12%) 10 (13%) A cutaneous abscess is defined as focal, confined purulent
SAH 18 (21%) 17 (21%) infection with a well-defined cavity surrounded by an in-
DM2 + SAH 16 (19%) 17 (21%) flammatory process involving deep subcutaneous tissues. On
DM2 + SAH + ESRD 0 2 ( 2%) physical examination, fluctuation suggests the presence of pus
None 40 (48%) 35 (43%) in the abscess cavity. Cellulitis, however, is a pyogenic in-
Abscess location 0.02b fection of the skin without an organized cavity and is typically
Face 18 (21%) 16 (20%) located in the epidermis, dermis, and shallow subcutaneous
Neck 4 ( 5%)c 0 tissues [14]. Because cellulitis constitutes the acute phase of an
Torso 2 ( 2%) 10 (12%)c SSTI, it is the only setting in which antibiotic agents are truly
Back 4 ( 5%) 2 ( 2%) indicated. An already developed abscess, however, is the result
Axila 2 ( 2%) 4 ( 5%)
Abdomen 6 ( 7%) 2 ( 2%)
Upper extremity 4 ( 5%) 6 ( 8%) Table 2. Outcome Parameters
Lower extremity 10 (12%) 4 ( 5%)
Inguinal 4 ( 5%) 1 ( 1%) Group 1 Group 2
Gluteal 10 (12%) 8 (11%) Parameter (antibiotic) (placebo) p
Peri-anal 8 (10%) 18 (22%)c N 84 81
Scrotal 2 ( 2%) 0
Surgical site 10 (12%) 10 (12%) Resolution at 7th day 0.28a
Yes 81 (96%) 75 (93%)
Leucocyte level 0.005a No 3 ( 4%) 6 ( 7%)
(103/mcL)
Mean – SD 13.9 – 3.7 12.3 – 3.4 Time to full healing 0.94a
Range 8.7–21.5 2.0–22.6 7 days 9 (11%) 10 (12%)
a 14 days 33 (39%) 30 (37%)
Abscess volume (mL) 0.85 21 days 32 (38%) 33 (41%)
Mean – SD 28 – 102 25 – 77 > 21 days 10 (12%) 8 (10%)
Range 2–685 5–480
VAS pain at 7th day 0.6b
a
Independent samples t-test. Mean – SD 1.6 – 0.9 1.7 – 0.9
b
Pearson w2 test. Range 1–4 1–4
c
Statistically different as shown by w2 post hoc testing.
a
SD = standard deviation; BMI = body mass index; DM2 = type 2 Pearson w2 test.
b
diabetes mellitus; SAH = systemic arterial hypertension; ESRD = end- Independent samples t-test.
stage renal disease. VAS = visual analogue scale; SD = standard deviation.
 ABSCESS MANAGEMENT 349

of the body’s defense mechanisms. In addition, pus consists
of a build-up of serum, dead neutrophils, necrotic tissue,
cholesterol and glucose. Most importantly, infective micro-
organisms do not always contribute to the pus composition.
In this regard, we believe that there is a misunderstanding
of the natural process of the development of an abscess,
leading physicians to believe that the presence of pus within
subcutaneous tissues constitutes the infectious material itself,
and consequently, to administer antibiotic agents. Also, we
have noted that medical staff at our institution prefer to
‘‘prevent’’ by admitting and prescribing broad-spectrum
antibiotic agents to patients with peri-anal abscesses or sur-
gical site infections (SSIs) because they are concerned about
the medical and legal consequences that may arise should
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abscesses are amenable to I&D alone, whereas in cases of
recurrent or refractory abscesses the presence of methicillin-
resistant Staphylococcus aureus (MRSA) should be sus-
pected and treated accordingly [24]. Recent studies, however,
reported that the outcomes of SSTIs treated with antibio-
tic agents were much the same regardless the activity of the
prescribed drug against the infecting organism as confirmed
by culture/antibiogram [25,26]. When cultures of patients
with SSTIs reported the presence of MRSA, all of those in-
fections improved even when b-lactamic antibiotic agents,
ineffective against this micro-organism, were administered
[6,27]. However, in a trial involving 1,265 patients with a
drained cutaneous abscess, Talan et al. [28] found that pa-
tients who received trimethoprim-sufamethoxazole (at doses

those infections progress to Fournier gangrene or necrotizing
fasciitis. According to the results of this study, however, this
premise is not only unnecessary but also exaggerated because
we managed every single patient on an outpatient basis and
observed no adverse outcomes (Fig. 2).
Although simple cases of cutaneous cellulitis and ab-
scesses are caused by gram-positive pathogens, it is common
for physicians to use broad-spectrum antibiotic agents against
gram-negative and anaerobic micro-organisms [15–18]. Med-
ical staff must remain aware that exposing patients to unnec-
essary, lengthy, and unwarranted broad-spectrum antibiotic
treatments is unacceptable in the current era of progressive
antimicrobial resistance [19–21] as well as the incidence and
severity of infection by Clostridium difficile [22,23].
Current guidelines of the American Society of Infectious
Diseases (ASID) and the U.S. Centers for Disease Control
and Prevention (CDC) state that uncomplicated cutaneous
of 320 and 1600 mg, respectively, twice daily, for 7 d) had a
higher cure rate than those who received placebo. The re-
searchers also found that many secondary outcomes were
better in the trimethoprim-sulfamethoxazole group than
in the placebo group, including fewer subsequent surgical
drainage procedures, new skin infections, and infections
among household members six to eight weeks after the end
of the treatment period.
Our study challenges the current recommendations of the
Clinical Practice Guidelines of Mexican Institute of Social
Security (IMSS-074-08) for the medical management of
SSTIs and SSIs. Both guidelines endorse the administration
of a variety of oral/intravenous antibiotic agents for such
types of infections [29]. The results of this study may well
serve for future updates in the aforementioned guidelines.
In this study we sought to determine any possible role of
antibiotic agents as adjunct treatment in the management of

FIG. 2. Image depicting resolution of infective process in a patient allocated to the placebo arm after incision and
drainage (I&D). (A) A large amount of pus was drained by I&D. (B) Incision packing with hypochlorite-moistured gauze.
(C) Incision bed appearance by seventh day. (D) Incision bed by 21st day. Note: because of the size of the surgical site, it
did not heal completely by 21st day. It did, however, resolve infective process, as no signs of ongoing infection/cellulitis
were seen by the seventh day (C).
 350
subcutaneous abscesses. No such a role could be identified.
Patients undergoing I&D resolved their infectious process at
a similar rate and time whether or not antibiotic agents were
prescribed. This was true even in patients with diabetes
mellitus and those older than 70 years. We also wanted to
determine whether antibiotic agents help decrease pain or
accelerate healing by acting synergistically with the im-
mune system. Such benefits were also ruled out according to
our results.
We have to recognize that ciprofloxacin was not the most
appropriate choice, even though it has activity against gram-
positive as well as gram-negative bacteria and one (not the
preferred) of their indications is soft tissue infections. As we
mentioned in the introduction, emergency department phy-
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sicians in our hospital often prescribe antibiotic agents and
admit patients to the surgical ward for diagnosis of subcu-
taneous abscess. By doing a little research, we identified ci-
profloxacin as one of the antibiotic agents most frequently
prescribed by our emergency department colleagues. The
reason why we decided to use it in our study was in part to
demonstrate that the same incorrectly prescribed antibiotic
(ciprofloxacin) is also unnecessary. Regarding the dose used,
the recommended therapeutic range of ciprofloxacin is 500–
1,500 mg/d. Because we excluded patients with complicated
disease or with conditions likely to lead to a complicated
outcome (necrotizing fasciitis, Fournier gangrene, diabetic
foot, etc.), we considered it appropriate to use the minimum
effective dose of the drug. Because evidence does not support
routine swabbing for culture in immunocompetent indi-
viduals [30], we did not send samples of pus for culture/
antibiogram at first I&D and reserved this measure only for
those patients who failed to progress satisfactorily. As stated
previously, no patient had to be admitted because of failure
of initial treatment.
Among the limitations of this study it should be noted that:
it was not properly powered and thus no methodologically
correct sample of patients was set for representativeness of
the population; it was single-blinded only, with the medical
consultant who performed follow-up revisions being aware
of the arm to which the patient had been allocated after
randomization; and it was a single-institution study, so the-
oretically, the results might not be widely applicable. There is
an inherent risk of bias as a result of these drawbacks. The
strengths of the study are: it was randomized and placebo-
controlled; it was a straightforward intervention, easily ap-
plicable in every institution; and its results may lead to a
better use of clinical resources and important savings for
health care institutions.
Conclusions
According to our results, I&D is the sole procedure required
for patients with uncomplicated subcutaneous abscess. Anti-
biotic agents do not confer any benefit to I&D and, in general,
are not warranted unless cellulitis without pus is present.
Multi-institutional, properly sized, and well-designed clinical
trials are needed to corroborate these results.
Acknowledgments
We declare that this manuscript has neither been published
nor being to be published elsewhere. Each author has made
important scientific contributions to the manuscript. All authors
LÓPEZ ET AL.
listed have agreed to submit in present form and declare that
there are no conflicts of interests.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Dr. Julio López
Department of Surgery
HGZ/MF 11 Mexican Institute of Social Security
Avenida Rio Conchos Poniente y 7a. Poniente S/N
Delicias, Chihuahua 33000
Mexico
E-mail: juliocesar1701@icloud.com