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Antibiotics for simple skin abscesses: the new evidence in perspective
  1. Bradley Frazee
  1. Department of Emergency Medicine, Alameda Health System—Highland Hospital, Oakland, California, USA
  1. Correspondence to Dr Bradley Frazee, Department of Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, CA 94602, USA; bradf_98{at}yahoo.com

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Two studies, both published in New England Journal of Medicine in the last 2 years, go a long way in answering, once and for all, whether antibiotics are beneficial after incision and drainage (I&D) of simple skin abscesses. This is an age-old question in emergency medicine and one that grew more urgent with the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in the late 1990s and early 2000s. While CA-MRSA can cause serious invasive infections, it predominantly causes skin and soft tissue abscesses, mostly simple furuncles in young, healthy patients. Between 1997 and 2005, for example, ED visits for skin and soft tissue infections rose more than 50%, with 59% of culturable infections due to MRSA.1 Do all these furuncles we are now seeing really require a prescription for MRSA-active antibiotics?

‘A strategy of routinely treating all skin abscesses with adjunctive antibiotics seems perfectly justified’.

There have been many studies over the last 40 years examining the benefit of adjunctive antibiotics (in addition to I&D) for simple skin abscesses, though most are small and low quality. A 2013 meta-analysis, which pooled the results of the 12 highest quality studies and focused in particular on MRSA infections, found no evidence of benefit with antibiotics.2 The 2014 Infectious Disease Society of America (IDSA) guidelines on skin and soft tissue infection treatment emphasise that providing good surgical drainage is the most important treatment for uncomplicated skin abscesses.3 The guidelines recommend reserving adjunctive antibiotics for complicated infections, defined as those with fever or toxicity, greater than 5 cm of surrounding cellulitis, or occurring in an immunocompromised host. Nonetheless, in an international poll of physicians who were given a hypothetical case of an uncomplicated skin abscess that had undergone I&D, only 31% voted for withholding adjunctive antibiotics. Respondents from North America were much more …

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