This month JC is looking at a fairly hot topic in the blogosphere namely, the routine use of antibiotics in the management of uncomplicated skin abscesses in the ED. We will review a recent randomized controlled trial (RCT) published in the NEJM by Dr. David Talan, a board certified EM and ID physician that some believe, provides sufficient evidence for a paradigm shift in our approach to patient management. In addition, two previously published articles will also be reviewed that presented data against the routine use of antibiotics in uncomplicated skin abscesses. Interestingly, in 2010, Dr. Talan wrote an accompanying editorial to one of them (Duong et al.) in support of deferred use of antibiotics. Also of interest, the latest (2014)  IDSA Guidelines recommends against the routine use of antibiotics in uncomplicated skin abscesses… “The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based upon presence or absence of systemic inflammatory response syndrome (SIRS).” 

The three tenets of EBM are best available evidence, clinical expertise and patient values and preferences. In our practice, a majority of patients with simple abscesses are seen by our PA colleagues and I would appreciate your coming out to share your insights. Is there sufficient evidence to recommend routine use of antibiotics in all uncomplicated abscesses or is this data not applicable to our patient population? 

 Duong M. et al. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med. 2010 May;55(5):401-7    Appraisal

Schmitz GR et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med. 2010 Sep;56(3):283-7  Appraisal

Talan DA, et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016 Mar 3;374(9):823-32.   Appraisal