Abscess Research Update # 1 - Draft 2 - Abigail McGuire

8/12/2019 Abscess Research Update # 1 - Draft 2 - Abigail McGuire

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Antibiotic Use in the Treatment of

Uncomplicated Cutaneous Abscesses

Dr. Abigail McGuire

Supervisor: Dr. Mathieu GatienMethodologist: Dr. Lisa Calder



Cutaneous Abscesses

• 2% of patient visits to the ED1

• Decision to prescribeantibiotics is variable

– 2012 prospective trial: 79.9%of physicians used both I&Dand antibiotics2

– 2011 retrospective cohortstudy: 88-98% of physiciansprescribed antibiotics3

http://www.daviddarling.info/encyclopedia/A/abscess.html



Management of Abscesses:What does the evidence show?

• 90.5 to 95% placebo cure rate – 2007 double-blind RCT of

cephalexin vs. placebo10 – 2010 pediatric double-blind

RCT of TMP-SMX vs. placebo11

• Even in MRSA prevalent areas

TMP-SMX offers no clinicalbenefit above I&D alone13

• Size, induration, erythema notcorrelated to treatment

failure11,12

• Bottom line: No currentevidence for antibiotics inaddition to I&D

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Research Project Objectives

• Question: Are our ED physiciansfollowing the best evidence-based practice in the

management of simplecutaneous abscesses?

• Primary Outcome Measure:

Proportion of TOH ED visits for

cutaneous abscesses for whichantibiotics are prescribed

http://www.terryarondberg.com/page/11/



Methods• Design: Retrospective Chart Review

• Setting: TOH EDs – Civic and General

Population: Patients presenting toTOH Emergency Departmentsbetween January 1, 2012 to August31, 2012 who meet the inclusion andexclusion criteria

http://media3.washingtonpost.com/wp-srv/photo/gallery/090417/GAL-09Apr17-1900/media/PHO-09Apr17-158575.jpg



Inclusion Criteria

• All patients dischargedfrom the ED at TOHbetween January 1, 2012

to August 31, 2012 withICD10 diagnosis ofcutaneous abscess – 257 patients

•

Patients ≥ 18 years of age• First presentation

http://www.strategystew.com/2009/04/27/whats-the-point-and-opportunity-of-tweet-chats/



Exclusion Criteria

• HR at Triage ≥ 120 • Temperature at Triage ≥ 38˚C • Systolic BP at Triage ≤ 90 mmHg • Non-cutaneous abscesses (intra-

abdominal, intra-thoracic etc.)

• Post-surgical or post proceduralwound abscesses• Documented human or animal

bite within 30 days prior to visit• Recurrent visit for skin abscess• Breast abscesses and/or mastitis• Genital abscesses• Peri-rectal and peri-anal

abscesses

• Patients already on antibiotics attime of ED visit

• Patients admitted to hospital as aresult of the ED visit for abscess

• Patients with abscessesassociated with arterial or venousinsufficiency ulcers or withunderlying gangrene

• Patients with unusual exposuressuch as underwater injury, heavysoil or farming injuries etc.

• Abscesses around prostheticmaterials

• Abscesses in areas of full-thickness burn wounds



Outcome Measures

• Primary Outcome Measure:

– Proportion of TOH ED visits for the first presentation ofuncomplicated cutaneous abscesses for which antibiotics wereprescribed

• Secondary Outcome Measures:

– Frequency of I &D; frequency of packing – Type, route, duration of antibiotics prescribed – Treatment failure (return to ED within 30 days) – Frequency of obtaining swabs and results of such C&S testing – Frequency of antibiotic prescription in specific patient groups:

• DM, MRSA+, Immunosuppressed, HIV+, IVDU, LTC, homeless, prison inmates

– Qualitative features of abscesses for which antibiotics were given:• Size of abscess (<5cm, ≥5cm), overlying cellulitis, location



Data Collection & Timeline

• Oct 2012: REB approval obtained• 257 patient records retrieved

• Oct 2012: Electronic dataabstraction sheet piloted andadjusted – 50% exclusion rate based on pilot

therefore expected N = 100-128

– Pre-determined values for missing

values on the EMR• Nov 2012: Start data abstraction

• March 2013: End data collection

• April 2013: Clean data & analyze

http://www.revenuexl.com/client-server-based-emr-ehr/



Data Analysis

• Primary outcome:

– Proportion with a 95% CIand p-value of ≤0.05

• Secondary outcomes: – The chi-squared test,

Fisher exact test, or the

student t-testhttp://www.keylogicsolutions.com/onetoonetraining.htm



Clinical Importance

• Antibiotics are not benign: – Increasing drug resistance

– Risk of adverse side effects

– Cost for patients

• Need to limit antibioticprescription to cases whereit is absolutely necessary

• Test of whether we are

adhering to evidence-basedpractice at TOH

UptoDate Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc

Toxic Epidermal Necrolysis

http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1232324374



Questions?

http://deltabiology.com/2011/bacteria-cartoon-comic/cartoon10/



References1. Rajendran PM, Young DM, Maurer T, Chambers HF, Jacobson MA, Harris HW. Antibiotic Use in The Treatment of Soft Tissue Abscesses: A

Survey of Current Practice. Surgical Infections. 2007;8(2):237-238.

2. May L, Harter K, Yadav K, et al. Practice patterns and management strategies for purulent skin and soft-tissue infections in an urbanacademic ED. The American Journal of Emergency Medicine. 2010;30(2):302-310.

3. Baumann BM, Russo CJ, Pavlik D, et al. Management of Pediatric Skin Abscesses in Pediatric, General Academic and Community EmergencyDepartments. Western Journal of Emergency Medicine. 2011;12(2).

4. Hammond SP, Baden LR. Management of Skin and Soft-Tissue Infection ‚Äî Polling Results. New England Journal of Medicine. 2008/10/092008;359(15):e20.

5. Merritt C, Mintzer J, Stricker J, Haran JP, Murphy L, Merchant RC. 130 More May Not Be Better: Are Emergency Department CliniciansOverdosing Abscess Patients With Antibiotics? Annals of Emergency Medicine. 2011;58(4, Supplement):S221.

6. Lee MC, Rios A, Aten M, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquiredmethicillin-resistant Staphylococcus aureus. Pediatric Infectious Disease Journal.2004;23(2):123-127.

7. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department. New

England Journal of Medicine. 2006/08/17 2006;355(7):666-674.

8. Paydar KZ, Hansen SL, Charlebois ED, Harris HW, Young DM. Inappropriate antibiotic use in soft tissue infections. Archives of Surgery.

2006;141(9):850-856.

9. Macfie J, Harvey J. The treatment of acute superficial abscesses: A prospective clinical trial. British Journal of Surgery. 1977;64(4):264-266.

10. Rajendran PM, Young D, Maurer T, et al. Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment ofUncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection.

Antimicrobial Agents and Chemotherapy.2007;51(11):4044-4048.11. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin

Abscesses in the Pediatric Patient. Annals of Emergency Medicine. 2010;55(5):401-407.

12. Chen AE, Carroll KC, Diener-West M, et al. Randomized Controlled Trial of Cephalexin Versus Clindamycin for Uncomplicated Pediatric SkinInfections. Pediatrics. 2011;127(3):e573-e580.

13. Schmitz GR, Bruner D, Pitotti R, et al. Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses inPatients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection. Annals of Emergency Medicine.

2010;56(3):283-287.

Abscess Research Update # 1 - Draft 2 - Abigail McGuire

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