CCBYNC Open access
Practice Rapid Recommendations

Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k243 (Published 06 February 2018) Cite this as: BMJ 2018;360:k243

Population

This recommendation applies to almost all patients with skin abscesses: People with skin abscesses Children and adults Unknown or unconfirmed pathogen(s) Smaller and larger abscesses Emergency and primary care settings However the recommendation is not applicable to patients with: Evidence of systemic illness (sepsis) Pustules and papules Deep tissue infections Immunocompromising conditions Hidradenitis suppurativa Patients who do not undergo incision and drainage

Comparison 1

or No antibiotics Antibiotics Incision and drainage plus trimethoprim and sulfamethoxazoleor clindamycin Incision and drainage alone No antibiotics Antibiotics + or CLI TMP SMX

We suggest TMP-SMX or clindamycin plus incision and drainage rather than incision and drainage alone. Discuss both options with each patient. All Applies to Click fordetails Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours no antibiotics Favours antibiotics Evidence quality Events per 1000 people Outcomes (1 month) No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

47 fewer Treatment failure High More 43 90

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics with activity against MRSA reduce the risk of treatment failure

63 fewer Recurrence Moderate More 66 129

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency Borderline Publication bias No serious concerns Antibiotics probably reduce the risk of early abscess recurrence

Invasive infections Moderate More 4 4 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of invasive infections
Evidence quality Events per 1000 people Outcomes (3–4 days)

68 fewer Pain (tenderness) Moderate More 491 559

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably reduce pain during treatment
Evidence quality Events per 1000 people Side effects (TMP-SMX)

Gastrointestinal side effects Moderate More 106 21 fewer 85

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of gastrointestinal side effects

11 fewer 24 Nausea Moderate More 35

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of nausea

No important difference Diarrhoea Moderate More 62 67

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of diarrhoea
Evidence quality Events per 1000 people Side effects (clindamycin)

Gastrointestinal side effects Moderate More 185 95 fewer 90

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of gastrointestinal side effects

Nausea Moderate More 23 24 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of nausea

Diarrhoea Moderate More 162 96 fewer 67

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of diarrhoea
See all outcomes (TMP-SMX)
See all outcomes (Clindamycin)
Different people probably place different values on the expected consequences (both desirable and undesirable) of taking antibiotics. Different individuals are likely to choose different treatment options. Shared decision making is needed to elicit these values and preferences. Preferences and values Antibiotic resistance Antibiotic use increases antibiotic resistance in the community and in recurrent infections in the individual. However, the impact of a single course of antibiotics is very uncertain. Key practical issues No antibiotics Antibiotics No practical issues Typically taken 2–3 times daily, for 5–10 days

Comparison 2

For patients who have chosen to initiate antibiotics: First and second generation cephalosporins or Trimethoprim andsulfamethoxazole or Clindamycin Cephalosporins Trimethoprim and sulfamethoxazoleor clindamycin Cephalosporins CEPH or CLI TMP SMX

We recommend trimethoprim and sulfamethoxazole or clindamycin over cephalosporins. Those initiating antibiotics Applies to Click fordetails Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours TMP-SMX Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 280 162 fewer 119

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns TMP-SMX probably reduces the risk of treatment failure
See all outcomes
Favours clindamycin Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 280 171 fewer 109

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Clindamycin probably reduces the risk of treatment failure
See all outcomes
No antibiotics Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 295 180 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Cephalosporins probably do not reduce the risk of treatment failure
See all outcomes
This strong recommendation applies to the most common situation where the risk of methicillin-resistant Staphylococcal aureus is more than 10%. MRSA The basis for this recommendation is that cephalosporins are probably less effective than TMP-SMX and clindamycin and they may not be more effective than placebo. Evidence interpretation Adverse effects Adverse effects differ between antibiotics. Key practical issues Trimethoprim and sulfamethoxazole Cephalosporins 2 pills, 2 times per day Typically less expensive Clindamycin 2 pills, 3 times per day Typically more expensive 1 pill 2-4 times per day Typically more expensive

Comparison 3

or Clindamycin Trimethoprim andsulfamethoxazole Clindamycin Trimethoprim and sulfamethoxazole For patients who have chosen to initiate antibiotics: CLI TMP SMX

We suggest trimethoprim and sulfamethoxazole over clindamycin. Discuss with patients in shared decision making. Those initiating antibiotics Click fordetails Applies to Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours clindamycin Favours TMP-SMX Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure High More 119 109 No important difference

Risk of Bias No serious concerns Imprecision Borderline Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is no important difference in treatment failure

Early recurrence Low More 135 67 fewer 68

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns TMP-SMX may result in higher risk of early abscess recurrence

Diarrhoea High More 162 109 fewer 53

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns TMP-SMX has a lower risk of diarrhoea

Nausea Moderate More 43 23 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably not an important difference in risk of nausea
See all outcomes
Different people probably place different values on the expected consequences (both desirable and undesirable) of taking antibiotics. Different individuals are likely to choose different treatment options. Shared decision making is needed to elicit these values and preferences. Preferences and values Antibiotic resistance Consider local resistance patterns when choosing the antibiotic as susceptibility patterns candiffer substantially. Key practical issues Clindamycin Trimethoprim and sulfamethoxazole 2 pills, 3 times per day Typically more expensive 2 pills, 2 times per day Typically less expensive

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Mieke Vermandere, general practitioner1,
  2. Bert Aertgeerts, chair, professor1 2,
  3. Thomas Agoritsas, assistant professor3 4,
  4. Catherine Liu, associate professor5,
  5. Jako Burgers, professor6 7,
  6. Arnaud Merglen, paediatrician8,
  7. Patrick Mbah Okwen, general practitioner9,
  8. Lyubov Lytvyn, patient partnership liaison3 10,
  9. Shunjie Chua, patient partner11,
  10. Per O Vandvik, assistant professor12 13,
  11. Gordon H Guyatt, distinguished professor3,
  12. Claudia Beltran-Arroyave, professor of paediatric infectious diseases14,
  13. Valéry Lavergne, medical microbiologist and infectious disease specialist15,
  14. Reinhart Speeckaert, dermatologist16,
  15. Finn E Steen, patient partner17,
  16. Victoria Arteaga, patient partner18,
  17. Rachelle Sender, general practitioner19,
  18. Shelley McLeod, assistant professor20,
  19. Xin Sun, professor21,
  20. Wen Wang, attending physician21,
  21. Reed A C Siemieniuk, methods editor, general internist3 22
  1. 1Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
  2. 2CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
  3. 3Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  4. 4Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
  5. 5Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center; Division of Allergy and Infectious Diseases, University of Washington
  6. 6Dutch College of General Practitioners, Utrecht, The Netherlands
  7. 7Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands
  8. 8Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
  9. 9Bali District Hospital, Bali, and Centre for Development of Best Practices in Health, Yaounde, Cameroon
  10. 10Oslo University Hospital, Blindern 0317 Oslo, Norway
  11. 11MOH Holdings, Singapore, Singapore 099253
  12. 12Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  13. 13Norwegian Institute of Public Health, Oslo, Norway
  14. 14Department of Paediatrics, Universidad de Antioquia, Medellín, Colombia
  15. 15Department of medical microbiology and infectious diseases, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
  16. 16Department of Dermatology, Ghent University Hospital, Ghent, Belgium
  17. 17BI Norwegian Business School, Oslo, Norway
  18. 18Medellín, Colombia
  19. 19Department of Family Medicine, McMaster University Medical School, Hamilton, Ontario, Canada
  20. 20Schwartz/Reisman Emergency Medicine Institute, Sinai Health System; Department of Family & Community Medicine, University of Toronto, Ontario, Canada
  21. 21Chinese Evidence-based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu 610041, China
  22. 22Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to: R Siemieniuk reed.siemieniuk{at}medportal.ca

What role do antibiotics have in the treatment of uncomplicated skin abscesses after incision and drainage? A recent study suggested that, for small uncomplicated skin abscesses, antibiotics after incision and drainage improve the chance of short term cure compared with placebo. Triggered by this trial, the Rapid Recommendation team produced a new systematic review. Relying on this review and using the GRADE framework according to the BMJ Rapid Recommendation process, an expert panel makes a weak recommendation in favour of trimethoprim-sulfamethoxazole (TMP-SMX, co-trimoxazole) or clindamycin in addition to incision and drainage over incision and drainage alone. For patients who have chosen to initiate antibiotics, the panel issues a strong recommendation for TMP-SMX or clindamycin rather than a cephalosporin and a weak recommendation for TMP-SMX rather than clindamycin. Box 1 shows the articles and evidence linked to this Rapid Recommendation. The infographic presents the recommendations together with other pertinent information, including an overview of the absolute benefits and harms of candidate antibiotics in the standard GRADE format. The panel emphasises shared decision making in the choice of whether to initiate antibiotics and in which antibiotic to use, because the desirable and undesirable consequences are closely balanced: clinicians using MAGICapp (http://magicapp.org/goto/guideline/jlRvQn/section/ER5RAn) will find decision aids to support the discussion with patients. Table 2 below shows any evidence that has emerged since the publication of this article.

What you need to know

  • For uncomplicated skin abscesses, we suggest using trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin in addition to incision and drainage rather than incision and drainage alone, and emphasise the need for shared decision making

  • TMP-SMX or clindamycin modestly reduces pain and treatment failure and probably reduces abscess recurrence, but increases the risk of adverse effects including nausea and diarrhoea

  • We suggest TMP-SMX rather than clindamycin because TMP-SMX has a lower risk of diarrhoea

  • Cephalosporins in addition to incision and drainage are probably not more effective than incision and drainage alone in most settings

  • From a societal perspective, the modest benefits from adjuvant antibiotics may not outweigh the harms from increased antimicrobial resistance in the community, although this is speculative

Box 1

Linked articles in this BMJ Rapid Recommendation cluster

  • Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018;360:k243

    • Summary of the results from the Rapid Recommendation process

  • Wang W, Chen W, Liu Y, et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ Open 2018;8:e020991

    • Review of all available randomised trials that assessed antibiotics for uncomplicated skin abscesses

  • MAGICapp (http://magicapp.org/goto/guideline/jlRvQn/section/ER5RAn)

    • Expanded version of the results with multilayered recommendations, evidence summaries, and decision aids for use on all devices

Current understanding

A skin abscess is an isolated collection of pus within the dermis and deeper skin tissues. Uncomplicated skin abscesses are collections of pus within the skin structures and are usually caused by bacterial infections. Careful history and clinical examination are usually sufficient to diagnose a skin abscess.123 Skin abscesses present as single or multiple tender, erythematous, indurated nodules, often surrounded by an area of erythema or swelling.1 Fluctuance beneath the skin often indicates a fluid filled cavity. There may be a pustule at the area where the abscess is closest to the skin or spontaneous drainage of pus.3 The use of point-of-care ultrasonography can help differentiate an abscess from other soft tissue infections in the emergency department.4

Skin infections are common. More than 4% of people seek treatment for skin infections annually in the United States.5 In European countries, it may be less common: in Belgium and the Netherlands about 0.5-0.6% visit their general practitioner with bacterial skin infections each year.678

Identifying the infecting pathogen may not be necessary for treating uncomplicated skin abscesses, but cultures can provide helpful information in patients with recurrent abscesses or systemic illness.13 The most common pathogens are Staphylococcus aureus, most often methicillin-resistant (MRSA), and several other bacteria, most originating from the skin flora.19MRSA accounts for a substantial number of visits by patients with skin and soft tissue infections.101112

Table 1 summarises current management guidelines, which do not recommend antibiotics for uncomplicated skin abscesses.

Table 1

Current recommendations for antibiotics in patients with skin abscesses*

View this table:

How the recommendation was created

The scope of the recommendation and the outcomes important to patients were defined by an international guideline panel consisting of two adults with lived experience of skin abscesses, one adult with lived experience as a carer for a child with skin abscess, five general practitioners, three paediatric or adult infectious disease physicians, four general internists, a general paediatrician, a dermatologist, and several health research methodologists. They requested a systematic review on the benefits and harms of different antibiotics to inform the recommendation.15 The panel then met online to discuss the evidence and to formulate specific recommendations. As with all BMJ Rapid Recommendations, no panel member had financial conflicts of interest; intellectual and professional conflicts were minimised and managed (see appendix 1 on bmj.com).17

The panel followed the BMJ Rapid Recommendations procedures for creating a trustworthy recommendation, including using the GRADE approach to critically appraise the evidence and to move from evidence to recommendations (appendix 2 on bmj.com).17313233 The panel initially identified patient-important outcomes and subgroup hypotheses needed to inform the recommendation. When creating the recommendation, the panel considered the balance of benefits, harms, costs, burdens of the treatments, the quality of evidence for each outcome, typical patient values and preferences and their expected variations, as well as acceptability.34 Recommendations can be strong or weak, for or against a course of action. The recommendations take a patient-centred perspective which de-emphasises public health, societal, and health payer point of view.

The evidence

To inform the recommendations, the guideline panel requested a systematic review of randomised controlled trials (RCTs) on the effects of adjuvant antibiotic therapy compared with no antibiotic therapy in addition to incision and drainage in patients with uncomplicated skin abscesses.15

A large RCT published in March 2016 suggested that TMP-SMX treatment resulted in a higher cure rate than placebo among patients with a drained cutaneous abscess.16 Another RCT published in June 2017 found that, compared with incision and drainage alone, clindamycin or TMP-SMX in addition to incision and drainage improved short term outcomes in patients who had an uncomplicated skin abscess.5 The Rapid Recommendations team believed these two trials, in addition to the existing body of evidence, might change practice.17

Figure 1 gives an overview of the characteristics of patients and trials included in the systematic review of the effects of antibiotics on uncomplicated skin abscesses. There were 14 RCTs: eight included a comparison of antibiotics versus no antibiotics, and seven included a comparison of two different antibiotics. Explicit descriptions of abscess definitions, for each trial, were summarised in the accompanying systematic review (table C of appendix 2).15 The largest trial specifically focused on small abscesses (all <5 cm diameter and about half ≤2 cm) in patients who had no signs of systemic infection.5 The RCTs included participants with skin abscesses anywhere on the body.

Fig 1
Fig 1

Characteristics of patients and trials included in systematic review of the effects of antibiotics on uncomplicated skin abscesses. (MRSA = meticillin resistant Staphylococcus aureus; MSSA = meticillin susceptible S aureus)

Eleven trials reported study setting, of which nine were conducted in emergency departments,516181920212223 one in outpatient dermatology clinics,24 and one in an Integrated Soft Tissue Infection Services (ISIS) clinic involving patients with high rates of comorbidity, such as infection with hepatitis C, hepatitis B, or HIV.25 The RCTs included children and adults. Almost all patients underwent incision and drainage for their skin abscess. The most common pathogen was MRSA (49-88%) followed by methicillin-sensitive Staphylococcus aureus (MSSA, 9-18%).

Understanding the recommendation

Absolute benefits and harms

The infographic provides an overview of the recommendations and the absolute benefits and harms of different antibiotics. Estimates of the baseline risk for side effects are derived from the control groups of the trials in the systematic review. Detailed information can also be viewed through MAGICapp, including consultation decision aids designed to support shared decision making with patients.26

This clinical practice guideline is applicable to patients with uncomplicated skin abscesses, which means that it is not applicable to patients with evidence of systemic illness (such as sepsis), deep tissue infections, superficial infections (such as pustules and papules), hidradenitis suppurativa, or immunocompromising conditions, and patients who do not undergo incision and drainage.

The first recommendation relates to the usefulness of adjuvant TMP-SMX or clindamycin compared with no antibiotics in addition to incision and drainage. The effects of other antibiotics are speculative, except for cephalosporins, which are probably less effective or not effective (see evidence summary for recommendation No 2). Compared with no antibiotics, TMP-SMX or clindamycin reduces the absolute risk of treatment failure by approximately 5% at one month (high quality evidence). In patients who were cured, these antibiotics reduced the absolute risk of recurrence at three months by approximately 8% (high quality evidence). When considering both treatment failure and abscess recurrence, antibiotic therapy thus provides an approximate 13% reduction (high quality evidence). TMP-SMX or clindamycin probably provides a modest reduction in pain (tenderness) during treatment (7% fewer), and a small reduction in hospitalisation (2% fewer) and in similar infections among household contacts (2% fewer) (all moderate quality evidence). Considering the characteristics of involved patients and medical conditions may differ between emergency departments and general practices, antibiotics may confer an even smaller benefit in patients who present to their GP. Antibiotics probably do not reduce the risk of serious or invasive infections or death (moderate quality evidence).

The occurrence of adverse effects depends on the antibiotic. With clindamycin, the risk of gastrointestinal side effects (predominately diarrhoea) is approximately 10% higher than with no antibiotics (high quality evidence). TMP-SMX probably increases the risk of gastrointestinal side effects by a smaller amount (approximately 2%; moderate quality evidence), and it is predominately nausea rather than diarrhoea. The severity of antibiotic-associated diarrhoea was not described, but is likely to range from mild to severe. Two large trials monitored for Clostridium difficile infection with routine clinical monitoring and no such infection occurred in any treatment arm.15

Overall, there is no important difference in treatment failure between TMP-SMX and clindamycin (high quality evidence). In patients who were initially cured, one study suggested that clindamycin may reduce the risk of early recurrence at one month by approximately 7% (low quality evidence),5 but the confidence interval was wide and this result is inconsistent with indirect evidence from other RCTs, which suggests that the reduction in risk of abscess recurrence compared with placebo is similar for both TMP-SMX and clindamycin. Whether clindamycin reduces abscess recurrence more than TMP-SMX is therefore uncertain (low quality evidence). Local resistance patterns may affect the relative effectiveness of each antibiotic option.27282930 Clindamycin has a 10% higher risk of antibiotic-associated diarrhoea than TMP-SMX (high quality evidence).

The panel also considered evidence for cephalosporins compared with TMP-SMX and clindamycin used for uncomplicated skin abscesses. The network meta-analysis suggested that, at least in settings with a substantial prevalence of MRSA, cephalosporins in addition to incision and drainage probably do not reduce treatment failure compared with incision and drainage alone (moderate quality evidence). Both early and later generation cephalosporins probably confer a higher risk of treatment failure compared with either TMP-SMX or clindamycin (moderate quality evidence). The RCTs investigating cephalosporins did not report sufficient information to directly compare other outcomes. However, the panel felt that cephalosporins were unlikely to provide any other benefits if they do not reduce the risk of treatment failure compared with placebo (low quality evidence). This evidence directly applies to almost all settings where the prevalence of MRSA is more than 10%.12

The panel is confident that the evidence applies to almost all patients with uncomplicated skin abscesses treated with incision and drainage: adults and children, patients presenting to emergency departments and to primary care practices, smaller and larger abscesses, first abscess occurrences and recurrences, and abscesses with unknown infection pathogens. The systematic review and meta-analyses contained adequate representation from such groups and settings, and results were consistent between pre-specified subgroups.15

Values and preferences

The panel believes that there is a high degree of variability between patients and carers weighing the expected desirable and undesirable consequences of antibiotic therapy compared with no antibiotic therapy. This variation is reflected in the weak recommendation, which warrants shared decision making to ensure that each individual’s decision is in line with what they consider most important. The expected benefit of antibiotic therapy in reducing pain, risk of treatment failure, and recurrence is modest, but large enough that the panel anticipates that most fully informed patients would value these benefits sufficiently to choose antibiotic treatment. This might particularly be the case when, for example, the abscess is very painful, perhaps because of location in sensitive places (such as groin, axillae, etc).

For patients who decide to initiate antibiotic treatment, reasonable choices include either TMP-SMX or clindamycin. In some settings, cephalosporins or other antibiotics are often prescribed for skin abscesses. Given that, in most circumstances, cephalosporins probably do not provide any additional benefit beyond incision and drainage alone, the panel felt that all or almost all patients would choose to use antibiotic options with proven efficacy (TMP-SMX or clindamycin), hence the strong recommendation against cephalosporins.

People who place a higher value on the possibility of avoiding abscess recurrence may choose clindamycin, while those who place a higher value on avoiding diarrhoea and on minimising costs are likely to prefer TMP-SMX.

Person-centred versus societal perspective (impact on antibiotic resistance)

The recommendations explicitly take a person-centred perspective rather than a public health or societal perspective. The use of antibiotics is associated with the emergence of antibiotic resistance within the community and may increase the risk of antibiotic resistant infections in community members. The increasing rates of antimicrobial resistance are a public health priority. From a societal perspective, it is possible that the modest benefits from adjuvant antibiotics in this scenario would not outweigh the risk of increased antimicrobial resistance in the community. However, the impact of an individual course of antibiotics on community resistance rates is unknown. Therefore, whether antibiotics in this situation provide a net benefit or harm to society is highly speculative. Clinicians engaging in shared decision making can also address the issue of antibiotic resistance or the local prevalence of other pathogens (such as Panton-Valentine leukocidin (PVL) positive Staphylococcus aureus) with patients facing this decision.

Practical issues and other considerations

Figure 2 outlines the key practical issues for patients and clinicians discussing initiating antibiotics for uncomplicated skin abscesses after incision and drainage, which are also accessible as decision aids along with the evidence in an expanded format to support shared decision making in MAGICapp. The antibiotic course was typically five to 10 days in the RCTs, and dosing varied. TMP-SMX may slightly increase the risk of congenital malformations, including neural tube defects, when prescribed to pregnant women.

Fig 2
Fig 2

Practical issues about use of antibiotics after incision and drainage of uncomplicated skin abscesses. (FDA = US Food and Drug Administration)

Costs and resources

TMP-SMX is inexpensive; clindamycin is probably more expensive in most places. However, the overall impact on costs to the individual and the healthcare payer are uncertain when the consequences of each option are considered.

Future research

Key research questions to inform decision makers and future guidelines are:

  • What is the impact of different types of antibiotics in settings where MRSA is rare (prevalence <10%)?

  • Do antibiotics have different effects in different populations, such as people who are immunocompromised or in people with recurrent skin abscesses?

  • What are the long term effects (such as >6 months) of antibiotics on abscess recurrence, Clostridium difficile infection, and MRSA resistance to TMP-SMX or clindamycin?

  • Is a shorter course of antibiotics (such as 5 days) as effective as a longer course (10 days)?

  • Is topical therapy (such as iodine, honey, silver, other antimicrobials) effective for treating uncomplicated skin abscesses compared with systemic therapy? Do other adjunctive measures, such as nasal decontamination or antisepsis for the body, reduce the risk that skin abscesses will recur?

Updates to this article

Table 2 shows evidence which has emerged since the publication of this article. As new evidence is published, a group will assess the new evidence and make a judgment on to what extent it is expected to alter the recommendation.

Table 2

New evidence which has emerged after initial publication

View this table:

Education into practice

  • Do you currently consider antibiotics for patients with uncomplicated skin abscesses after surgical treatment?

  • What information could you share with your patient to help reach a decision together?

  • Would you consider using online decision aid tools (such as the one available on MAGICapp) to facilitate shared decision making?

How patients were involved in the creation of this article

Three people with lived experience of skin abscesses were full panel members: two had previously experienced skin abscesses before (one with recurrent abscesses), and one person is a parent of a child who experienced a skin abscess. These panel members identified patient-important outcomes, and led the discussion on values and preferences. These patient partners agreed that, although pain reduction was the most important outcome to them, these values may not be shared by all patients. The close balance between desirable and undesirable consequences made it difficult for them (and the panel) to decide which options most individuals would choose.

Footnotes

  • This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (www.magicproject.org) and The BMJ. A summary is offered here and the full version including decision aids is on the MAGICapp (www.magicapp.org), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. We encourage adaptation and contextualisation of our recommendations to local or other contexts. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article.

  • Competing interests: All authors have completed the BMJ Rapid Recommendations interests disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 2 on bmj.com. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

  • Funding: This guideline was not funded. R Siemieniuk is partially funded through a Vanier Canada Graduate Scholarship.

  • Transparency: B Aertgeerts affirms that the manuscript is an honest, accurate, and transparent account of the recommendation being reported; that no important aspects of the recommendation have been omitted; and that any discrepancies from the recommendation as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

References

View Abstract