Skin and Soft Tissue Infections - Incision, Drainage, and Debridement Periprocedural Care

Consent should be obtained from the patient or family member, when appropriate. ^[6] The reason the procedure is being performed (suspected diagnosis); the risks, benefits, and alternatives of the procedure; the risks and benefits of the alternative procedure; and the risks and benefits of not undergoing the procedure. Allow the patient the opportunity to ask any questions and address any concerns they may have. Make sure that they have an understanding about the procedure so they can make an informed decision.

The patient should be counseled about the risks of bleeding (damage to adjacent blood vessels), dissemination of infection (sepsis, endocarditis), and injury of local nerves.

The patient should also be counseled that even if there are no complications, the procedure may not be successful (the abscess may not be completely drained, additional surgery may be necessary).

Discuss how these risks can be avoided or prevented (eg, adequate analgesia, use of ultrasound when possible or indicated, use of antibiotics when indicated).

Controlling the source of infection is the key to management of skin and soft-tissue infections (SSTIs) because it is the fastest way of decreasing the bacterial load. ^[7] Source control is achieved by means of pus drainage and debridement (see Technique). The aim of debridement is to create an acute wound milieu so as to trigger the body’s natural wound healing mechanisms and thereby promote healing.

In addition to surgical management of an SSTI, selected investigations, antibiotic therapy, or both may be indicated.

Laboratory tests

Patients with uncomplicated SSTIs usually do not require any investigations and need not be hospitalized. However, immunocompromised patients or those with symptoms and signs of systemic toxicity, such as tachycardia and hypotension, may require the following tests:

• Wound culture

• Blood culture and drug susceptibility

• Complete blood cell (CBC) count with differential

• Creatinine level

• Bicarbonate level

• Creatine phosphokinase level

• C-reactive protein level

Additional investigations may be indicated, depending on the severity of systemic toxicity.

Antimicrobial therapy

Uncomplicated SSTIs with no symptoms or signs of systemic involvement respond well to incision and drainage and appropriate wound care. Patients with relatively small abscesses usually do not require any antibiotics. However, evidence has shown that even in the absence of associated cellulitis, antibiotics may hasten the resolution of an abscess after drainage, so this should be considered in larger abscesses or those with significant associated inflammation. The extent of abscess must be confirmed and complete drainage ensured at the time of surgical exploration.

In the setting of systemic disease or an immunocompromised host, blood and wound cultures are recommended. Oral or intravenous (IV) antimicrobial therapy is then started empirically, depending on the severity of the infection. ^[8]

The following are indications for IV antibiotics:

• A severe soft-tissue infection is limb- or life-threatening

• The signs and symptoms of systemic illness are present

• The patient is immunosuppressed

• The patient is at the extremes of age

Empirical antimicrobial therapy is administered as follows:

• Semisynthetic penicillins or second-generation cephalosporins are given to cover S aureus

• Site-specific antibiotics are given to cover indigenous organisms

• Appropriate antibiotics are given to cover methicillin-resistant S aureus (MRSA) if suspected

• Broad-spectrum antibiotics are given to patients with complicated SSTIs and immunocompromised status

After identification of the organism or organisms and confirmation of drug sensitivity, appropriate antimicrobials are started.

Less commonly used FDA-approved antibiotics for the treatment of acute bacterial skin and skin structure infections include oritavancin (Orbactiv), dalbavancin (Dalvance), and tedizolid (Sivextro),. These agents are active against S aureus (including methicillin-susceptible S aureus and MRSA] isolates), Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus anginosus group (includes Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus), among others. For complete drug information, including dosing, see the following monographs:

• Oritavancin

• Dalbavancin

• Tedizolid

Guidelines

The Infectious Diseases Society of America updated their guidelines for the diagnosis and management of SSTIs in 2014. For the full guidelines, see Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. ^{[9, 10]}

The equipment required for incision, drainage, and debridement is the basic surgical set, which may include the following:

• Sponge-holding forceps

• Surgical blade, Nos. 11 and 15

• Curved artery forceps

• Plane and toothed thumb forceps

• Curette

• Metzenbaum scissors

• Sterile swab stick

• Electrocautery

• Saline

• Hydrogen peroxide

Patient preparation includes adequate anesthesia and appropriate positioning.

Anesthesia

Anesthesia for incision and drainage is as follows:

• General anesthesia: This used for large and deep abscesses to facilitate complete and thorough drainage. 
• Regional anesthesia: This can be used for large and deep abscesses if patient cooperation can be ensured.
• Field block: This is used for small to medium-sized abscesses.
• Local anesthesia: The overlying skin is anesthetized via a 26-gauge needle, and the anesthetic is infiltrated subcutaneously into the dome of the abscess to achieve anesthesia of the skin to enable painless skin incision; anesthetizing the abscess cavity is not very effective, because the local anesthetic functions poorly in the acidic environment of the abscess.

Anesthesia for debridement is as follows:

• General anesthesia: Because debridement is a very painful procedure, and complete analgesia is essential for thorough debridement.
• Regional anesthesia or field block: This may be used when general anesthesia is not desirable and patient cooperation can be ensured.

Positioning

The patient is positioned in accordance with the location of the lesion. Whichever position is chosen should afford the surgeon easy access to the lesion and should be comfortable for the patient.

Patients with complicated SSTIs or necrotizing fasciitis may have bloodstream infection (BSI) and experience septic shock. Such patients are kept under close monitoring and may require intensive care nursing. Depending on the severity of the BSI and septic shock, the patient may require intensive monitoring, along with supportive measures aimed at maintaining circulation and ventilation.