EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success
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Contents
Clinical Question
Does irrigation of cutaneous abscesses in the ED reduce the need for further intervention?
Conclusion
Irrigation of cutaneous abscesses after standard incision and drainage does not decrease the need for further intervention, and may be unnecessary.
Major Points
The treatment of cutaneous abscesses classically involves the incision and drainage procedure. Historically, this procedure involves making a linear incision over the abscess cavity, followed by manual expression of cavity contents, blunt dissection to break up loculations, further irrigation with saline, and packing with gauze. However, a lack of data supports the routine use of irrigation to improve the success of the procedure and treatment of the abscess. In addition, while not typically considered, the routine use of irrigation does include some downsides: extra time and supplies, cost, and the possibility of microbiologic contamination of the patient care area and body fluid exposure to the practitioner.
The authors of this study randomized patients to I&D with or without irrigation to determine which method best treated cutaneous abscesses. While there were some differences in the baseline characteristics of the study (higher incidence of packing and antibiotic usage in the Irrigation Group), these differences would presumably improve the outcomes of these patients; a finding that was not demonstrated. Ultimately, the authors concluded that irrigation of cutaneous abscesses did not decrease the need for further intervention and may not be necessary during an I&D procedure.
Study Design
Prospective, randomized, non blinded, single center trial comparing irrigation with no irrigation. The study was conducted in an academic ED with an annual census of ~110,00 patients.
Population
Patient and Abscess Baseline Characteristics
Median age was slightly lower in the Irrigation Group. Irrigation group had a slightly higher rate of overlying cellulitis.
| Patient Characteristics | Irrigation (95) | No Irrigation (92) |
| Median Age | 35 | 40 |
| Cellulitis | 61% | 51% |
| Diabetes | 17% | 16% |
| Fever | 3% | 2% |
| Immunocompromised | 3% | 2% |
There was no major difference in the size of the abscesses.
| Abscess Size | Irrigation | No Irrigation |
| Median | 4.6 cm Irrigation | 4.3 cm No Irrigation |
| Range | 3-10 cm Irrigation | 1-11 cm No Irrigation |
Abscess location did not differ amongst groups.
| Abscess Location | Irrigation | No Irrigation |
| Face, Scalp | 5% | 9% |
| Neck | 3% | 5% |
| Chest, Breast, Back, Abdomen, Inguinal | 13% | 22% |
| Buttocks | 20% | 16% |
| Perineum, Perianal, Labial, Scrotal | 7% | 4% |
| Leg, foot | 19% | 21% |
There was a significant increase in the percent of patients who had packing in the Irrigation Group, as well as post procedure ABX's.
| Post Procedure | Irrigation | No Irrigation |
| Abscess Packed | 89% | 75% |
| IV ABX in ED | 3% | 8% |
| PO ABX in ED | 42% | 43% |
| ABX Rx’d | 91% | 73% |
Inclusion Criteria
- Patients over the age of 18 with a cutaneous abscess
Exclusion Criteria
- Pregnancy
- In police custody or prison resident
- Patients admitted to the hospital
- Operating room I&D
- Inability to follow up in 48 hours, or to provide contact information for 30 day follow up
Interventions
The intervention was to perform irrigation or no irrigation during the I&D procedure in the ED. Out of the 209 patients randomized, 105 were assigned to the irrigation group and 104 to the no irrigation group.
For the irrigation group, the type of solution and amount used was at the providers discretion. The most commonly used irrigant was a 100 mL NSS in a squeeze bottle with a small caliber tip that can fit in an abscess pocket.
Outcomes
Primary Outcome
Need for further intervention during subsequent 30 days. Predefined as one of the following: repeat I&D, ABX change, hospital admission for abscess related condition
- Irrigation Group: 14 pts (15%)
- No Irrigation Group: 12 pts (13%)
- The only patient who required subsequent admission for the abscess was from the no irrigation group
Difference of 2%; 95% CI -8 to 12%
Secondary Outcomes
Visual analog pain score post procedure
- Irrigation Group: 5.6
- No Irrigation Group: 5.7
Difference 0.1; 95% CI -0.7 to 0.9
Criticisms & Further Discussion
- Lack of standardization of irrigation technique for the Irrigation Group
- Lack of standardization of packing and ABX usage, which lead to differences in these treatments in the two groups (irrigation group having increased rates of both)
- Relatively high use of ABX overall (82% of patients); may partly be explained by overall high incidence of overlying cellulitis in patients of both groups
- Performed in a single institution
- Further studies should evaluate a population with a lower incidence of cellulitis, and thus less incidence of ABX usage.
- The use of ABX, as well as packing, is also of controversial benefit
See Also
Funding
No funding was reported for this study.
