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

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. 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. 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 absce