Abscess
| Abscess | |
|---|---|
| Classification and external resources | |
 Abscess |
|
| ICD-10 | L02 |
| ICD-9 | 682.9, 324.1 |
| MeSH | D000038 |
An abscess (Latin: abscessus) is a collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue in which the pus resides on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.
The organisms or foreign materials kill the local cells, resulting in the release of cytokines. The cytokines trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.
The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.
Abscesses must be differentiated from empyemas, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity.
Contents |
Signs and symptoms
The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules (boils) or deep skin abscesses), in the lungs, brain, teeth, kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death (gangrene). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess. An abscess could potentially be fatal (although this is rare) if it compresses vital structures such as the trachea in the context of a deep neck abscess.
Treatment
Wound abscesses do not generally need to be treated with antibiotics, but they will require surgical intervention, debridement and curettage.[1]
Incision and drainage
The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics.[2]
Surgical drainage of the abscess (e.g., lancing) is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage. This is expressed in the Latin medical aphorism: Ubi pus, ibi evacua.
In critical areas where surgery presents a high risk, it may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the respiratory tract. Warm compresses and elevation of the limb may be beneficial for a skin abscess.
Packing
In North America, after drainage, an abscess cavity is often packed. However, there is no evidence to support this practice and it may in fact delay healing.[3] To try to answer this question more definitely, a randomized double-blind study was started in September 2008 and is ongoing as of December 2008.[4] Interim analysis of data from this study suggests that "wound packing may significantly increase the failure rates." [5] A small pilot study has found no benefit from packing of simple cutaneous abscesses.[6]
Primary closure
Primary closure has been successful when combined with curettage and antibiotics[7] or with curettage alone.[8] However, another randomized controlled trial found primary closure led to 35% failing to heal primarily and primary closure longer median number of days to closure (8.9 versus 7.8).[9]
In anorectal abscesses, primary closure healed faster, but 25% of abscesses healed by secondary intention and recurrence was higher.[10]
Antibiotics
As Staphylococcus aureus bacteria is a common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. These antibiotics may also be prescribed to patients with a documented allergy to penicillin. (If the condition is thought to be cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin in patients able to tolerate penicillin). It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels. Whilst most medical texts advocate surgical incision some medical doctors will treat small abscesses conservatively with antibiotics.
Recurrent infections
Recurrent abscesses are often caused by community-acquired MRSA. While resistant to most beta lactam antibiotics commonly used for skin infections, it remains sensitive to alternative antibiotics, e.g., clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), and doxycycline (unlike hospital-acquired MRSA that may only be sensitive to vancomycin IV).
To prevent recurrent infections due to Staphylococcus, consider the following measures:
- Topical mupirocin applied to the nares.[11] In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.
- Chlorhexidine baths,[12] In a randomized controlled trial, nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach statistical significance, the baths are an easy treatment.
Magnesium sulfate paste
Historically abscesses as well as boils and many other collections of pus have been treated via application of magnesium sulfate (Epsom salt) paste. This works by drawing the infected pus to the surface of the skin before rupturing and leaking out, after this the body will usually repair the old infected cavity. Magnesium sulfate is therefore best applied at night with a sterile dressing covering it, the rupture itself is not painful but the drawing up may be uncomfortable. Magnesium sulfate paste is considered a "home remedy" and is not necessarily an effective or accepted medical treatment.
Perianal abscess
Perianal abscesses can be seen in patients with for example inflammatory bowel disease (such as Crohn's disease) or diabetes. Often the abscess will start as an internal wound caused by ulceration or hard stool. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus which grows larger and more painful with the passage of time.
Like other abscesses, perianal abscesses may require prompt medical treatment, such as an incision and debridement or lancing.
See also
- Tooth abscess
- Brain abscess
- Hidradenitis suppurativa
References
- ↑ McLatchie G, Leaper D, (eds). 2007. Oxford Handbook of Clinical Surgery, 2nd ed. Oxford. OUP
- ↑ Green, James; Saj Wajed (2000). Surgery: Facts and Figures. Cambridge University Press. ISBN 1900151960.
- ↑ "BestBets: abscesses; to pack or not to pack". http://www.bestbets.org/bets/bet.php?id=272.
- ↑ "Study of Wound Packing After Superficial Skin Abscess Drainage - Full Text View - ClinicalTrials.gov". http://clinicaltrials.gov/ct2/show/NCT00746109.
- ↑ "Randomized Clinical Trial of Packing Following Incision and Drainage of Superficial Skin Abscesses in the Pediatric Emergency Department". http://aap.confex.com/aap/2009/webprogram/Paper5982.html.
- ↑ O'Malley GF, Dominici P, Giraldo P, et al. (April 2009). "Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary". Acad Emerg Med 16 (5): 470–3. doi:10.1111/j.1553-2712.2009.00409.x. PMID 19388915.
- ↑ Abraham N, Doudle M, Carson P (1997). "Open versus closed surgical treatment of abscesses: a controlled clinical trial". The Australian and New Zealand journal of surgery 67 (4): 173–6. doi:10.1111/j.1445-2197.1997.tb01934.x. PMID 9137156.
- ↑ Stewart MP, Laing MR, Krukowski ZH (1985). "Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial". The British journal of surgery 72 (1): 66–7. doi:10.1002/bjs.1800720125. PMID 3881155.
- ↑ Simms MH, Curran F, Johnson RA, et al. (1982). "Treatment of acute abscesses in the casualty department". British medical journal (Clinical research ed.) 284 (6332): 1827–9. doi:10.1136/bmj.284.6332.1827. PMID 6805714.
- ↑ Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 4-year follow-up". Acta Chirurgica Scandinavica 150 (8): 689–92. PMID 6397949.
- ↑ Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y (1996). "A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection". Arch Intern Med 156 (10): 1109–12. doi:10.1001/archinte.156.10.1109. PMID 8638999.
- ↑ Watanakunakorn C, Axelson C, Bota B, Stahl C (1995). "Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents". Am J Infect Control 23 (5): 306–9. doi:10.1016/0196-6553(95)90061-6. PMID 8585642.
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