Abscess

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Abscess
Other names Latin: Abscessus
Five day old Abscess Extra Low Contrast B.jpg
Five-day-old inflamed epidermal inclusion cyst. The black spot is a keratin plug which connects with the underlying cyst.
Specialty General surgery, infectious disease, dermatology
Symptoms Redness, pain, swelling [1]
Usual onsetRapid
Causes Bacterial infection (often MRSA) [1]
Risk factors Intravenous drug use [2]
Diagnostic method Ultrasound, CT scan [1] [3]
Differential diagnosis Cellulitis, sebaceous cyst, necrotising fasciitis [3]
Treatment Incision and drainage, Antibiotics [4]
Frequency~1% per year (United States) [5]

An abscess is a collection of pus that has built up within the tissue of the body. [1] Signs and symptoms of abscesses include redness, pain, warmth, and swelling. [1] The swelling may feel fluid-filled when pressed. [1] The area of redness often extends beyond the swelling. [6] Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger. [7] A cyst is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall.

Contents

They are usually caused by a bacterial infection. [8] Often many different types of bacteria are involved in a single infection. [6] In many areas of the world, the most common bacteria present is methicillin-resistant Staphylococcus aureus . [1] Rarely, parasites can cause abscesses; this is more common in the developing world. [3] Diagnosis of a skin abscess is usually made based on what it looks like and is confirmed by cutting it open. [1] Ultrasound imaging may be useful in cases in which the diagnosis is not clear. [1] In abscesses around the anus, computer tomography (CT) may be important to look for deeper infection. [3]

Standard treatment for most skin or soft tissue abscesses is cutting it open and drainage. [4] There appears to be some benefit from also using antibiotics. [9] A small amount of evidence supports not packing the cavity that remains with gauze after drainage. [1] Closing this cavity right after draining it rather than leaving it open may speed healing without increasing the risk of the abscess returning. [10] Sucking out the pus with a needle is often not sufficient. [1]

Skin abscesses are common and have become more common in recent years. [1] Risk factors include intravenous drug use, with rates reported as high as 65% among users. [2] In 2005, 3.2 million people went to American emergency departments for abscesses. [5] In Australia, around 13,000 people were hospitalized in 2008 with the condition. [11]

Signs and symptoms

An abscess Abszess.jpg
An abscess

Abscesses may occur in any kind of tissue but most frequently within the skin surface (where they may be superficial pustules known as boils or deep skin abscesses), in the lungs, brain, teeth, kidneys, and tonsils. Major complications may include spreading of the abscess material to adjacent or remote tissues, and extensive regional tissue death (gangrene). [12]

A naturally drained abscess phoNdd'aar chbi.jpg
A naturally drained abscess

The main symptoms and signs of a skin abscess are redness, heat, swelling, pain, and loss of function. There may also be high temperature (fever) and chills. [13] If superficial, abscesses may be fluctuant when palpated; this wave-like motion is caused by movement of the pus inside the abscess. [14]

An internal abscess is more difficult to identify, but signs include pain in the affected area, a high temperature, and generally feeling unwell. Internal abscesses rarely heal themselves, so prompt medical attention is indicated if such an abscess is suspected. An abscess can potentially be fatal depending on where it is located. [15] [16]

Causes

Risk factors for abscess formation include intravenous drug use. [17] Another possible risk factor is a prior history of disc herniation or other spinal abnormality, [18] though this has not been proven.

Abscesses are caused by bacterial infection, parasites, or foreign substances. Bacterial infection is the most common cause, particularly Staphylococcus aureus. The more invasive methicillin-resistant Staphylococcus aureus (MRSA) may also be a source of infection, though is much rarer. [19] Among spinal subdural abscesses, methicillin-sensitive Staphylococcus aureus is the most common organism involved. [18]

Rarely parasites can cause abscesses and this is more common in the developing world. [3] Specific parasites known to do this include dracunculiasis and myiasis. [3]

Anorectal abscess

Anorectal abscesses can be caused by non-specific obstruction and ensuing infection of the glandular crypts inside of the anus or rectum. Other causes include cancer, trauma, or inflammatory bowel diseases. [20]

Incisional abscess

An incisional abscess is one that develops as a complication secondary to a surgical incision. It presents as redness and warmth at the margins of the incision with purulent drainage from it. [21] If the diagnosis is uncertain, the wound should be aspirated with a needle, with aspiration of pus confirming the diagnosis and availing for Gram stain and bacterial culture. [21]

Pathophysiology

An abscess is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body. [22] [23]

Organisms or foreign materials destroy the local cells, which results 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. [23]

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. [23]

Diagnosis

Ultrasound showing dark (hypoechoic) area involving skin and subcutaneous tissue with moving internal debris in keeping with abscess [24]
Ultrasound image showing an abscess, appearing as a mushroom-shaped dark (hypoechoic) area within the fibroglandular tissue of the breast Ultrasound image of breast 110323101432 1023060.jpg
Ultrasound image showing an abscess, appearing as a mushroom-shaped dark (hypoechoic) area within the fibroglandular tissue of the breast

An abscess is a localized collection of pus (purulent inflammatory tissue) caused by suppuration buried in a tissue, an organ, or a confined space, lined by the pyogenic membrane. [25] Ultrasound imaging can help in a diagnosis. [26]

Classification

Abscesses may be classified as either skin abscesses or internal abscesses. Skin abscesses are common; internal abscesses tend to be harder to diagnose, and more serious. [13] Skin abscesses are also called cutaneous or subcutaneous abscesses. [27]

IV drug use

For those with a history of intravenous drug use, an X-ray is recommended before treatment to verify that no needle fragments are present. [17] If there is also a fever present in this population, infectious endocarditis should be considered. [17]

Differential

Abscesses should be differentiated from empyemas, which are accumulations of pus in a preexisting, rather than a newly formed, anatomical cavity. [28]

Other conditions that can cause similar symptoms include: cellulitis, a sebaceous cyst, and necrotising fasciitis. [3] Cellulitis typically also has an erythematous reaction, but does not confer any purulent drainage. [21]

Treatment

The standard treatment for an uncomplicated skin or soft tissue abscess is the act of opening and draining. [4] There does not appear to be any benefit from also using antibiotics in most cases. [1] A small amount of evidence did not find a benefit from packing the abscess with gauze. [1]

Incision and drainage

Abscess five days after incision and drainage Cleaned abscess day 5.jpg
Abscess five days after incision and drainage
Abscess following curettage HumeralAbscess.jpg
Abscess following curettage

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, incising and draining the abscess is standard treatment. [4] [29]

Antibiotics

Most people who have an uncomplicated skin abscess should not use antibiotics. [4] Antibiotics in addition to standard incision and drainage is recommended in persons with severe abscesses, many sites of infection, rapid disease progression, the presence of cellulitis, symptoms indicating bacterial illness throughout the body, or a health condition causing immunosuppression. [1] People who are very young or very old may also need antibiotics. [1] If the abscess does not heal only with incision and drainage, or if the abscess is in a place that is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated. [1]

In those cases of abscess which do require antibiotic treatment, Staphylococcus aureus bacteria is a common cause and an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. The Infectious Diseases Society of America advises that the draining of an abscess is not enough to address community-acquired methicillin-resistant Staphylococcus aureus (MRSA), and in those cases, traditional antibiotics may be ineffective. [1] Alternative antibiotics effective against community-acquired MRSA often include clindamycin, doxycycline, minocycline, and trimethoprim-sulfamethoxazole. [1] The American College of Emergency Physicians advises that typical cases of abscess from MRSA get no benefit from having antibiotic treatment in addition to the standard treatment. [4]

Culturing the wound is not needed if standard follow-up care can be provided after the incision and drainage. [4] Performing a wound culture is unnecessary because it rarely gives information which can be used to guide treatment. [4]

Packing

In North America, after drainage, an abscess cavity is usually packed, often with special iodoform-treated cloth. This is done to absorb and neutralize any remaining exudate as well as to promote draining and prevent premature closure. Prolonged draining is thought to promote healing. The hypothesis is that though the heart's pumping action can deliver immune and regenerative cells to the edge of an injury, an abscess is by definition a void in which no blood vessels are present. Packing is thought to provide a wicking action that continuously draws beneficial factors and cells from the body into the void that must be healed. Discharge is then absorbed by cutaneous bandages and further wicking promoted by changing these bandages regularly. However, evidence from emergency medicine literature reports that packing wounds after draining, especially smaller wounds, causes pain to the person and does not decrease the rate of recurrence, nor bring faster healing, or fewer physician visits. [30]

Loop drainage

More recently, several North American hospitals have opted for less-invasive loop drainage over standard drainage and wound packing. In one study of 143 pediatric outcomes, a failure rate of 1.4% was reported in the loop group versus 10.5% in the packing group (P<.030), [31] while a separate study reported a 5.5% failure rate among the loop group. [32]

Primary closure

Closing an abscess immediately after draining it appears to speed healing without increasing the risk of recurrence. [10] This may not apply to anorectal abscesses as while they may heal faster, there may be a higher rate of recurrence than those left open. [33]

Prognosis

Even without treatment, skin abscesses rarely result in death, as they will naturally break through the skin. [3] Other types of abscess are more dangerous. Brain abscesses may be fatal if untreated. When treated, the mortality rate reduces to 5–10%, but is higher if the abscess ruptures. [34]

Epidemiology

Skin abscesses are common and have become more common in recent years. [1] Risk factors include intravenous drug use, with rates reported as high as 65% among users. [2] In 2005, in the United States 3.2 million people went to the emergency department for an abscess. [5] In Australia around 13,000 people were hospitalized in 2008 for the disease. [11]

Society and culture

The Latin medical aphorism " ubi pus, ibi evacua " expresses "where there is pus, there evacuate it" and is classical advice in the culture of Western medicine. [35]

Needle exchange programmes often administer or provide referrals for abscess treatment to injection drug users as part of a harm reduction public health strategy. [36] [37]

Etymology

An abscess is so called "abscess" because there is an abscessus (a going away or departure) of portions of the animal tissue from each other to make room for the suppurated matter lodged between them. [38]

The word carbuncle is believed to have originated from the Latin: carbunculus, originally a small coal; diminutive of carbon-, carbo: charcoal or ember, but also a carbuncle stone, "precious stones of a red or fiery colour", usually garnets. [39]

Other types

The following types of abscess are listed in the medical dictionary: [40]

Related Research Articles

<i>Staphylococcus aureus</i> Species of Gram-positive bacterium

Staphylococcus aureus is a gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive for catalase and nitrate reduction and is a facultative anaerobe that can grow without the need for oxygen. Although S. aureus usually acts as a commensal of the human microbiota, it can also become an opportunistic pathogen, being a common cause of skin infections including abscesses, respiratory infections such as sinusitis, and food poisoning. Pathogenic strains often promote infections by producing virulence factors such as potent protein toxins, and the expression of a cell-surface protein that binds and inactivates antibodies. S. aureus is one of the leading pathogens for deaths associated with antimicrobial resistance and the emergence of antibiotic-resistant strains, such as methicillin-resistant S. aureus (MRSA). The bacterium is a worldwide problem in clinical medicine. Despite much research and development, no vaccine for S. aureus has been approved.

Methicillin-resistant <i>Staphylococcus aureus</i> Bacterium responsible for difficult-to-treat infections in humans

Methicillin-resistant Staphylococcus aureus (MRSA) is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans. It caused more than 100,000 deaths worldwide attributable to antimicrobial resistance in 2019.

<span class="mw-page-title-main">Carbuncle</span> Cluster of boils caused by bacterial infection

A carbuncle is a cluster of boils caused by bacterial infection, most commonly with Staphylococcus aureus or Streptococcus pyogenes. The presence of a carbuncle is a sign that the immune system is active and fighting the infection. The infection is contagious and may spread to other areas of the body, or other people; those living in the same residence may develop carbuncles at the same time. In the early 21st century, infection involving methicillin-resistant Staphylococcus aureus (MRSA) has become more common.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

<span class="mw-page-title-main">Boil</span> Medical condition (infection)

A boil, also called a furuncle, is a deep folliculitis, which is an infection of the hair follicle. It is most commonly caused by infection by the bacterium Staphylococcus aureus, resulting in a painful swollen area on the skin caused by an accumulation of pus and dead tissue. Boils are therefore basically pus-filled nodules. Individual boils clustered together are called carbuncles. Most human infections are caused by coagulase-positive S. aureus strains, notable for the bacteria's ability to produce coagulase, an enzyme that can clot blood. Almost any organ system can be infected by S. aureus.

An epidural abscess refers to a collection of pus and infectious material located in the epidural space superficial to the dura mater which surrounds the central nervous system. Due to its location adjacent to brain or spinal cord, epidural abscesses have the potential to cause weakness, pain, and paralysis.

<span class="mw-page-title-main">Paronychia</span> Medical condition

Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans. The term is from Greek: παρωνυχία from para 'around', onyx 'nail', and the abstract noun suffix -ia.

<span class="mw-page-title-main">Mastoiditis</span> Middle ear disease

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear. The mastoid process contains open, air-containing spaces. Mastoiditis is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times.

<span class="mw-page-title-main">Ludwig's angina</span> Form of severe cellulitis of the mouth floor

Ludwig's angina is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, the floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with drooling and difficulty speaking. As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. Overall, this condition has a rapid onset over a few hours.

<span class="mw-page-title-main">Flucloxacillin</span> Penicillin

Flucloxacillin, also known as floxacillin, is an antibiotic used to treat skin infections, external ear infections, infections of leg ulcers, diabetic foot infections, and infection of bone. It may be used together with other medications to treat pneumonia, and endocarditis. It may also be used prior to surgery to prevent Staphylococcus infections. It is not effective against methicillin-resistant Staphylococcus aureus (MRSA). It is taken by mouth or given by injection into a vein or muscle.

<span class="mw-page-title-main">Pyomyositis</span> Medical condition

Pyomyositis is a bacterial infection of the skeletal muscles which results in an abscess. Pyomyositis is most common in tropical areas but can also occur in temperate zones.

<span class="mw-page-title-main">Dicloxacillin</span> Chemical compound

Dicloxacillin is a narrow-spectrum β-lactam antibiotic of the penicillin class. It is used to treat infections caused by susceptible (non-resistant) Gram-positive bacteria. It is active against beta-lactamase-producing organisms such as Staphylococcus aureus, which would otherwise be resistant to most penicillins. Dicloxacillin is available under a variety of trade names including Diclocil (BMS).

<span class="mw-page-title-main">Orbital cellulitis</span> Inflammation of eye tissues

Orbital cellulitis is inflammation of eye tissues behind the orbital septum. It is most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses or through the blood. It may also occur after trauma. When it affects the rear of the eye, it is known as retro-orbital cellulitis.

<span class="mw-page-title-main">Anorectal abscess</span> Medical condition

Anorectal abscess is an abscess adjacent to the anus. Most cases of perianal abscesses are sporadic, though there are certain situations which elevate the risk for developing the disease, such as diabetes mellitus, Crohn's disease, chronic corticosteroid treatment and others. It arises as a complication of paraproctitis. Ischiorectal, inter- and intrasphincteric abscesses have been described.

Incision and drainage (I&D), also known as clinical lancing, are minor surgical procedures to release pus or pressure built up under the skin, such as from an abscess, boil, or infected paranasal sinus. It is performed by treating the area with an antiseptic, such as iodine-based solution, and then making a small incision to puncture the skin using a sterile instrument such as a sharp needle or a pointed scalpel. This allows the pus to escape by draining out through the incision.

<span class="mw-page-title-main">Dalbavancin</span> Antibiotic used to treat MRSA

Dalbavancin, sold under the brand names Dalvance in the US and Xydalba in the EU among others, is a second-generation lipoglycopeptide antibiotic medication. It belongs to the same class as vancomycin, the most widely used and one of the treatments available to people infected with methicillin-resistant Staphylococcus aureus (MRSA).

<span class="mw-page-title-main">Staphylococcal infection</span> Medical condition

A staphylococcal infection or staph infection is an infection caused by members of the Staphylococcus genus of bacteria.

<span class="mw-page-title-main">Ceftaroline fosamil</span> Chemical compound

Ceftaroline fosamil (INN), brand name Teflaro in the US and Zinforo in Europe, is a cephalosporin antibiotic with anti-MRSA activity. Ceftaroline fosamil is a prodrug of ceftaroline. It is active against methicillin-resistant Staphylococcus aureus (MRSA) and other Gram-positive bacteria. It retains some activity of later-generation cephalosporins having broad-spectrum activity against Gram-negative bacteria, but its effectiveness is relatively much weaker. It is currently being investigated for community-acquired pneumonia and complicated skin and skin structure infection.

Skin and skin structure infections (SSSIs), also referred to as skin and soft tissue infections (SSTIs), or acute bacterial skin and skin structure infections (ABSSSIs), are infections of skin and associated soft tissues. Historically, the pathogen involved has most frequently been a bacterial species—always, since redescription of SSSIs as ABSSSIs—and as such, these infections require treatment by antibiotics.

<span class="mw-page-title-main">Diabetic foot infection</span> Medical condition

Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.

References

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  33. ↑ Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up". Acta Chirurgica Scandinavica. 150 (8): 689–692. PMID   6397949.
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  39. ↑ OED, "Carbuncle": 1 stone, 3 medical
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