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Minimally invasive technique in treatment of complex, subcutaneous abscesses in children
Journal of Pediatric Surgery (2010) 45, 1562–1566
www.elsevier.com/locate/jpedsurg
Operative technique
Minimally invasive technique in treatment of complex, subcutaneous abscesses in children☆ Alan P. Ladd a,⁎, Marc S. Levy b , Jennifer Quilty b a
Division of Pediatric Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202 , USA Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
b
Received 6 January 2010; revised 12 February 2010; accepted 22 March 2010
Key words: Abscess, complicated; Methicillin-resistant Staphylococcus aureus; Surgery; Children; Minimally invasive
Abstract The rising prevalence of community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) has correlated with an escalating number of complex, subcutaneous abscesses in pediatric patients. The purpose of this study was to present a novel technique and early outcome results for the minimally invasive drainage of complex, subcutaneous abscesses. Methods: Patients' outcomes from the treatment of complex, subcutaneous abscesses were retrospectively reviewed under institutional review board approval from July 2006 to August 2007 at 2 independent, tertiary care pediatric hospitals. Data on patients' demographics, length of hospital stay, and length of treatment were collected, along with analysis of the isolated organisms. The operative technique uses drainage of the abscess through peripheral stab incisions. Cavity debridement and irrigation is followed by placement of a vessel-loop drain through the drainage incisions. Topical wound care without packing is performed twice a day. Drain removal follows resolution of cellulitis and drainage. Results: One hundred twenty-eight patients were treated over a 14-month period. The ratio of females to males was 1.25:1. Average patient age was 51.5 months (median, 21 months) and ranged from 5 weeks to 18 years. The average length of hospital stay was 1.5 days, though 30 patients were treated on an outpatient basis. Methicillin-resistant Staphylococcus aureus was identified in 76% of the cultured specimens. Average length of drain use was 9 days (range, 5-29 days). There were no local recurrences of subcutaneous abscesses. There was no morbidity related to the drainage procedures. Conclusion: We present a successful technique for the drainage and treatment of complex abscesses in children with limited, postoperative wound care and no morbidity or recurrence. © 2010 Elsevier Inc. All rights reserved.
The treatment of subcutaneous abscesses has long fallen to the techniques of incision and drainage with tissue debridement and subsequent wound care to allow for healing by secondary intention. Complicated abscesses of the subcuta☆ Presented at Pacific Association of Pediatric Surgeons 41st Annual Meeting June 30-July 3, 2008, Jackson Lake, Wyoming. ⁎ Corresponding author. Tel.: +1 317 274 4682; fax: +1 317 274 4491. E-mail address: [email protected] (A.P. Ladd).
0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.03.025
neous tissue often portend a greater morbidity as wider incision and drainage techniques are used for appropriate drainage and continued wound packing to maintain a welldebrided and clean wound that promotes healing and closure. The escalating incidence of community acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in the pediatric population has lead to a concurrent marked surge in numbers of skin infections with abscess formation requiring surgical drainage. Annual increases in prevalence
Treatment of complex, subcutaneous abscesses of subcutaneous abscess requiring operative drainage in pediatric populations have been reported to rise 7- to 10-fold over periods of 2 to 3 years in some pediatric referral centers [1,2]. These MRSA soft tissue infections often present as more complicated forms of subcutaneous abscesses, usually necessitating wide incision and drainage procedures for appropriate care. The surgical interventions often leave disfiguring wounds that require lengthy care that is often difficult for families without medical background. Attempts have been made to identify less invasive techniques for the care of these complicated infections in children that would not lessen the success of surgical management. We herein describe a novel technique that has been used that is less invasive and minimizes the morbidity and duration of wound care for our pediatric patients. The aim of this article is to thoroughly report our initial experience with this technique and provide short-term outcome results for this minimally invasive approach to complicated subcutaneous abscesses in children.
1. Methods Our operative technique uses an initial stab incision of the skin at the identified site of origin of the subcutaneous process. The noted site often had evidence of localized dermal necrosis or spontaneous drainage but rarely was fluctuant at the time of drainage. Expressed material was analyzed by aerobic and anaerobic cultures. The subcutaneous cavity was probed to determine the margin of greatest distance from the site of origin. A second, peripheral incision was made at this outer margin of the cavity. At the discretion of the surgeon based upon the size of the underlying cavity, a silastic vessel loop or 1/4 inch penrose drain was threaded
1563 through the 2 incisions, and its ends were ligated to produce a contiguous drain (Figs. 1 and 2). Occasional abscess cavities with extensive subcutaneous dissection required more than one counter incision with additional drain placement to provide appropriate drainage, often in a radial pattern from the point of origin. Loculations within the cavity were bluntly debrided or curetted with a resulting confluent cavity. The cavity was irrigated with either normal saline or one half strength hydrogen peroxide, at the discretion of the operative surgeon. The wound was compressed for final expression of residual necrotic tissue and suppurative contents. A dry gauze sponge was applied to cover the drainage sites, with no subcutaneous packing. The patients underwent twice a day wound soaks and/or topical cleansing with dressing changes. The drain was removed after resolution of cellulitis, peripheral skin induration, and wound drainage, with topical wound care continued until the incisions were fully healed. Operative cases from pediatric patients with complex, subcutaneous abscesses treated by this technique were reviewed over a 14-month period from July 1, 2006, to August 30, 2007. The review was performed at 2 independent, tertiary-care pediatric hospitals who shared the integration of the technique into clinical practice. Patient cases were identified as those undergoing operative intervention with drain placement among all operative cases for the treatment of complex, subcutaneous abscesses by search of institutional databases under institutional review board approval at each institution (EX0709-07 [IN], 07090310 [FL]). Consecutive cases at each institution using this technique were included in the review. Use of this technique versus classic linear incision and drainage with subsequent wound packing was at the discretion of the operative surgeon. Hospital and office records were reviewed for data on patient gender demographics, site of
Fig. 1 Operative Technique for minimally invasive drainage of complex abscesses (used with permission; © 2008 Indiana University School of Medicine). A, Presenting abscess with extensive subdermal necrosis. B, Operative process with drainage through peripheral incisions and drain placement, often in radial pattern (see text). C-D, Representations of abscess decompression following drainage with wound contraction around sub-dermal drain.
1564
A.P. Ladd et al.
2. Results
Fig. 2 (A-B) Clinical photo progression of abscess drainage of proximal thigh.
infection, mechanism of drainage, organism isolated from culture, length of stay, and postoperative morbidity and mortality. As our study only included those patients treated at our respective tertiary-care pediatric hospitals, outcomes for patients greater that 18 years of age were not available. Early experience with this technique did not include the management of abscesses within primary neck sites or the diagnoses of suppurative lymphadenitis, pilonidal abscess, or perianal abscess and/or fistula. The use of parenteral antibiotics was not standardized within our retrospective study but was often less than 24 hours postoperatively, once clinical resolution of fever and skin cellulitis was achieved. Parenteral administration of vancomycin or clindamycin was most often used in perioperative treatment. Antibiotic coverage was often continued after hospital discharge with the use of combination therapy with trimethoprim/sulfamethoxazole until time of drain removal. Most surgical techniques were performed under general anesthesia, but the technique was also used during conscious sedation as part of outpatient or observational treatment.
A total of 128 children underwent operative drainage of a complex abscess with this technique over the 14-month period. The median age for the population was 21 months and ranged from 5 weeks to 18 years. As illustrated in Fig. 3, the age distribution of our study population resembles a skewed population peaking at less than 24 months of age. The gender distribution of female to male patients was 1.25 to 1, respectively. Fig. 4 illustrates the results from the cultures obtained at time of abscess drainage. Of the 101 patients from whom cultures were obtained and results were available, 77 (76%) were MRSA and 14 (14%) were methicillin-sensitive Staphylococcus aureus. Data on the actual number of drains used within each procedure were available from 96 operative procedures and varied among the population reviewed. Sixty-seven patients (70%) required insertion of a single drain. Whereas, 29 patients (30%) required the concurrent placement of additional drains, up to 4, in their operative management. Length of hospitalization for those children treated as inpatients was 1.5 days, on average. With increased use of and comfort with this technique, it has been used in the outpatient or observational care of 30 more recent patients. Surgeon preferences lead to any patient selection bias for outpatient treatment. Parenteral antibiotics were not continued on an outpatient basis. Duration of drain placement was often dictated by convenience of outpatient follow-up. Patients were reexamined at an elective, outpatient clinic visit. Drain removal was performed after clinical evidence of resolution of cellulitis, skin induration, and drainage. Among the 108 patients for which data are available, the median length of time for drain use was 8 days, ranging from 3 to 29 days. Patient follow-up extended only to the date of drain removal in this retrospective study. Over the 14-month time frame reviewed, there were no patients who re-presented to surgical attention with same site recurrences of subcutaneous abscesses. There were no reports of infection extending to sites outside the operative field or to additional distal sites after operative drainage. No progression to systemic illness was identified after this technique. There were no deaths.
3. Discussion The prevalence of community-acquired MRSA in the pediatric population is ever increasing. Although the presence of community-acquired strains of MRSA was described earlier in adult populations, the rise of this disease in children is now well documented in the published literature [3,4]. Communities across the United States have reported a prevalence of MRSA at 66% to 74% among their pediatric patients undergoing surgical intervention [1,2]. Remarkably, this escalation in prevalence is often only over a
Treatment of complex, subcutaneous abscesses
Fig. 3
1565
Prevalence of complex, subcutaneous abscesses by patient age (months).
few years. A high prevalence of MRSA is also depicted in our own study, as culture specimens cumulatively reached 76% and was 67% among abscesses drained at an author's single institution (APL). Although this study was not able to identify associated risk factors for MRSA within our population, review of patient age at time of intervention suggests that a toddler population, less than 3 years of age, is at greatest risk. Presumably, this finding may be explained by the associated lack of formal toilet training and the use of diapers in this age group that may promote a local environment conducive to bacterial propagation. Standard of care in the treatment of subcutaneous abscesses has been through incision and drainage. Although routine incision, drainage, and debridement of a superficial suppurative process are often adequate for smaller abscesses often treated as outpatients or through an emergency department, abscesses larger than 5 cm often require formal surgical intervention [5,6]. The drainage of these larger
Fig. 4 Isolated organisms from 101 cultured abscesses. MSSA indicates methicillin-sensitive Staphylococcus aureus.
abscesses has often implicated the routine need for dressing changes that consist of classic wound packing and healing by secondary intention. Modifications to this surgical paradigm that opens and/or removes the superficial dermis of the abscess cavity for subsequent wound packing have been described. These modifications include simple large linear incisional drainage without packing, incision with curettage and primary wound closure with antibiotic coverage, or the insertion of a draining Pezzer catheter for wound decompression and healing [7-9]. Each of these published techniques has been exclusively described in adult populations with reported similar outcomes to standard wide incision and drainage, often with reduced pain and time to wound closure. The use of such techniques has remained regionalized. In addition, none of these studies described their use in populations affected with MRSA. The presented technique maintains the surgical paradigm of abscess treatment. The procedure not only allows the surgeon to adequately drain the contained suppurative material, reduce loculations within the subcutaneous tissue, and curette and/or debride the necrotic tissue contained within the abscess but also allows for the ongoing drainage of the wound by the prevention of premature skin annealing. Where the greatest benefit is seen with this technique, however, is in the obviation of the need to routinely pack these often large subcutaneous cavities in affected children. We would also contend that the ability to effectively heal the associated wounds without the need for wound packing reduces treatment noncompliance in this pediatric population. This technique offers both ease of use not only to both the surgeon as either a formal operative technique or one performed under conscious sedation but also to the patient's family as simple wound cleansing and cover dressings are all that is required after drainage.
1566 It is the authors' experience that the described technique has its greatest impact in the treatment of the larger, subcutaneous processes common to extensive MRSA soft tissue infection. Although not formally captured in the retrospective review of our patient population, typical abscesses encountered were greater than 5 cm in greatest diameter. Although the point of origin is often easily identified and occasionally shows evidence of partial decompression of the underlying suppurative process, these large abscesses demonstrate expansive cellulitis with marginal fluctuance to the underlying process, until extensive subcutaneous tissue destruction is present. These complex, often interdigitating, subcutaneous processes, were often best drained with numerous drain placements, to allow for formal drainage and debridement of each loculation. In the presented series, 30% of the patients required more than a single drain placement, to allow for appropriate decompression of the underlying suppurative process. We cannot draw any conclusions from this study on the necessity of postoperative antibiotic treatment in our population of pediatric patients. Despite contemporary publications refuting the routine use of antibiotics after drainage techniques, these publications have often excluded patients with either abscesses greater than 5 cm or with abscesses that manifest a significant degree of associated cellulitis, often seen with MRSA infections [10,11]. Although not standardized in this retrospective review, it was the authors' preference to treat patients preoperatively with parenteral antibiotics and continue parenteral coverage until regression of clinical cellulitis was apparent. Antibiotic coverage was often continued until the time of drain removal, often 7 to 9 days after drainage, with trimethoprim/ sulfamethoxazole coverage. Additional study is needed to determine the actual necessity of postoperative coverage with parenteral or enteral antibiotics in attempts to minimize the inpatient length of stay of these patients, which averaged 1.5 days. Further study is warranted to fully evaluate this procedure's ultimate success in treatment through long-term
A.P. Ladd et al. outcome analysis, as well as its acute impact on morbidity from the implied reduction in pain experienced by these pediatric patients postoperatively. However, as illustrated in the early outcomes from this study, the described technique is safe and effective in a pediatric population with a high prevalence of MRSA, with no reported recurrence of disease or failure to effectively treat, and having the additional benefit of eliminating repetitive wound packing in the treatment of this young population.
References [1] Seal J, Glynn L, Statter M, et al. A high prevalence of methicillinresistant Staphylococcus aureus among surgically drained soft-tissue infections in pediatric patients. Pediatr Surg Int 2006;22:683-7. [2] Faden H, Rose R, Lesse A, et al. Clinical and molecular characteristics of staphylococcal skin abscesses in children. J Pediatr 2007;151:700-3. [3] Herold BD, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593-8. [4] Frank AL, Marcinak JF, Mangat PD, et al. Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children. Pediatr Infect Dis 1999;18:993-1000. [5] O'Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med 2009;16:470-3. [6] Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department—part I. J Emerg Med 1985;3: 227-32. [7] Sorensen CC. Linear incision and curettage vs. deroofing and drainage in subcutaneous abscess. A randomized clinical trial. Acta Chir Scand 1987;153:659-60. [8] Abraham N, Doudle M, Carson P. Open versus closed surgical treatment of abscesses: a controlled clinical trial. Aust N Z J Surg 1997;67:173-6. [9] Philip RS. A simplified method for the incision and drainage of abscesses. Am J Surg 1978;135:721. [10] Hankin A, Everett WW. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med 2007;50:49-51. [11] Lee MC, Rios AM, Fonseca Aten M, et al. Management and outcome of children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2004;23:123-7.
www.elsevier.com/locate/jpedsurg
Operative technique
Minimally invasive technique in treatment of complex, subcutaneous abscesses in children☆ Alan P. Ladd a,⁎, Marc S. Levy b , Jennifer Quilty b a
Division of Pediatric Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202 , USA Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
b
Received 6 January 2010; revised 12 February 2010; accepted 22 March 2010
Key words: Abscess, complicated; Methicillin-resistant Staphylococcus aureus; Surgery; Children; Minimally invasive
Abstract The rising prevalence of community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) has correlated with an escalating number of complex, subcutaneous abscesses in pediatric patients. The purpose of this study was to present a novel technique and early outcome results for the minimally invasive drainage of complex, subcutaneous abscesses. Methods: Patients' outcomes from the treatment of complex, subcutaneous abscesses were retrospectively reviewed under institutional review board approval from July 2006 to August 2007 at 2 independent, tertiary care pediatric hospitals. Data on patients' demographics, length of hospital stay, and length of treatment were collected, along with analysis of the isolated organisms. The operative technique uses drainage of the abscess through peripheral stab incisions. Cavity debridement and irrigation is followed by placement of a vessel-loop drain through the drainage incisions. Topical wound care without packing is performed twice a day. Drain removal follows resolution of cellulitis and drainage. Results: One hundred twenty-eight patients were treated over a 14-month period. The ratio of females to males was 1.25:1. Average patient age was 51.5 months (median, 21 months) and ranged from 5 weeks to 18 years. The average length of hospital stay was 1.5 days, though 30 patients were treated on an outpatient basis. Methicillin-resistant Staphylococcus aureus was identified in 76% of the cultured specimens. Average length of drain use was 9 days (range, 5-29 days). There were no local recurrences of subcutaneous abscesses. There was no morbidity related to the drainage procedures. Conclusion: We present a successful technique for the drainage and treatment of complex abscesses in children with limited, postoperative wound care and no morbidity or recurrence. © 2010 Elsevier Inc. All rights reserved.
The treatment of subcutaneous abscesses has long fallen to the techniques of incision and drainage with tissue debridement and subsequent wound care to allow for healing by secondary intention. Complicated abscesses of the subcuta☆ Presented at Pacific Association of Pediatric Surgeons 41st Annual Meeting June 30-July 3, 2008, Jackson Lake, Wyoming. ⁎ Corresponding author. Tel.: +1 317 274 4682; fax: +1 317 274 4491. E-mail address: [email protected] (A.P. Ladd).
0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.03.025
neous tissue often portend a greater morbidity as wider incision and drainage techniques are used for appropriate drainage and continued wound packing to maintain a welldebrided and clean wound that promotes healing and closure. The escalating incidence of community acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in the pediatric population has lead to a concurrent marked surge in numbers of skin infections with abscess formation requiring surgical drainage. Annual increases in prevalence
Treatment of complex, subcutaneous abscesses of subcutaneous abscess requiring operative drainage in pediatric populations have been reported to rise 7- to 10-fold over periods of 2 to 3 years in some pediatric referral centers [1,2]. These MRSA soft tissue infections often present as more complicated forms of subcutaneous abscesses, usually necessitating wide incision and drainage procedures for appropriate care. The surgical interventions often leave disfiguring wounds that require lengthy care that is often difficult for families without medical background. Attempts have been made to identify less invasive techniques for the care of these complicated infections in children that would not lessen the success of surgical management. We herein describe a novel technique that has been used that is less invasive and minimizes the morbidity and duration of wound care for our pediatric patients. The aim of this article is to thoroughly report our initial experience with this technique and provide short-term outcome results for this minimally invasive approach to complicated subcutaneous abscesses in children.
1. Methods Our operative technique uses an initial stab incision of the skin at the identified site of origin of the subcutaneous process. The noted site often had evidence of localized dermal necrosis or spontaneous drainage but rarely was fluctuant at the time of drainage. Expressed material was analyzed by aerobic and anaerobic cultures. The subcutaneous cavity was probed to determine the margin of greatest distance from the site of origin. A second, peripheral incision was made at this outer margin of the cavity. At the discretion of the surgeon based upon the size of the underlying cavity, a silastic vessel loop or 1/4 inch penrose drain was threaded
1563 through the 2 incisions, and its ends were ligated to produce a contiguous drain (Figs. 1 and 2). Occasional abscess cavities with extensive subcutaneous dissection required more than one counter incision with additional drain placement to provide appropriate drainage, often in a radial pattern from the point of origin. Loculations within the cavity were bluntly debrided or curetted with a resulting confluent cavity. The cavity was irrigated with either normal saline or one half strength hydrogen peroxide, at the discretion of the operative surgeon. The wound was compressed for final expression of residual necrotic tissue and suppurative contents. A dry gauze sponge was applied to cover the drainage sites, with no subcutaneous packing. The patients underwent twice a day wound soaks and/or topical cleansing with dressing changes. The drain was removed after resolution of cellulitis, peripheral skin induration, and wound drainage, with topical wound care continued until the incisions were fully healed. Operative cases from pediatric patients with complex, subcutaneous abscesses treated by this technique were reviewed over a 14-month period from July 1, 2006, to August 30, 2007. The review was performed at 2 independent, tertiary-care pediatric hospitals who shared the integration of the technique into clinical practice. Patient cases were identified as those undergoing operative intervention with drain placement among all operative cases for the treatment of complex, subcutaneous abscesses by search of institutional databases under institutional review board approval at each institution (EX0709-07 [IN], 07090310 [FL]). Consecutive cases at each institution using this technique were included in the review. Use of this technique versus classic linear incision and drainage with subsequent wound packing was at the discretion of the operative surgeon. Hospital and office records were reviewed for data on patient gender demographics, site of
Fig. 1 Operative Technique for minimally invasive drainage of complex abscesses (used with permission; © 2008 Indiana University School of Medicine). A, Presenting abscess with extensive subdermal necrosis. B, Operative process with drainage through peripheral incisions and drain placement, often in radial pattern (see text). C-D, Representations of abscess decompression following drainage with wound contraction around sub-dermal drain.
1564
A.P. Ladd et al.
2. Results
Fig. 2 (A-B) Clinical photo progression of abscess drainage of proximal thigh.
infection, mechanism of drainage, organism isolated from culture, length of stay, and postoperative morbidity and mortality. As our study only included those patients treated at our respective tertiary-care pediatric hospitals, outcomes for patients greater that 18 years of age were not available. Early experience with this technique did not include the management of abscesses within primary neck sites or the diagnoses of suppurative lymphadenitis, pilonidal abscess, or perianal abscess and/or fistula. The use of parenteral antibiotics was not standardized within our retrospective study but was often less than 24 hours postoperatively, once clinical resolution of fever and skin cellulitis was achieved. Parenteral administration of vancomycin or clindamycin was most often used in perioperative treatment. Antibiotic coverage was often continued after hospital discharge with the use of combination therapy with trimethoprim/sulfamethoxazole until time of drain removal. Most surgical techniques were performed under general anesthesia, but the technique was also used during conscious sedation as part of outpatient or observational treatment.
A total of 128 children underwent operative drainage of a complex abscess with this technique over the 14-month period. The median age for the population was 21 months and ranged from 5 weeks to 18 years. As illustrated in Fig. 3, the age distribution of our study population resembles a skewed population peaking at less than 24 months of age. The gender distribution of female to male patients was 1.25 to 1, respectively. Fig. 4 illustrates the results from the cultures obtained at time of abscess drainage. Of the 101 patients from whom cultures were obtained and results were available, 77 (76%) were MRSA and 14 (14%) were methicillin-sensitive Staphylococcus aureus. Data on the actual number of drains used within each procedure were available from 96 operative procedures and varied among the population reviewed. Sixty-seven patients (70%) required insertion of a single drain. Whereas, 29 patients (30%) required the concurrent placement of additional drains, up to 4, in their operative management. Length of hospitalization for those children treated as inpatients was 1.5 days, on average. With increased use of and comfort with this technique, it has been used in the outpatient or observational care of 30 more recent patients. Surgeon preferences lead to any patient selection bias for outpatient treatment. Parenteral antibiotics were not continued on an outpatient basis. Duration of drain placement was often dictated by convenience of outpatient follow-up. Patients were reexamined at an elective, outpatient clinic visit. Drain removal was performed after clinical evidence of resolution of cellulitis, skin induration, and drainage. Among the 108 patients for which data are available, the median length of time for drain use was 8 days, ranging from 3 to 29 days. Patient follow-up extended only to the date of drain removal in this retrospective study. Over the 14-month time frame reviewed, there were no patients who re-presented to surgical attention with same site recurrences of subcutaneous abscesses. There were no reports of infection extending to sites outside the operative field or to additional distal sites after operative drainage. No progression to systemic illness was identified after this technique. There were no deaths.
3. Discussion The prevalence of community-acquired MRSA in the pediatric population is ever increasing. Although the presence of community-acquired strains of MRSA was described earlier in adult populations, the rise of this disease in children is now well documented in the published literature [3,4]. Communities across the United States have reported a prevalence of MRSA at 66% to 74% among their pediatric patients undergoing surgical intervention [1,2]. Remarkably, this escalation in prevalence is often only over a
Treatment of complex, subcutaneous abscesses
Fig. 3
1565
Prevalence of complex, subcutaneous abscesses by patient age (months).
few years. A high prevalence of MRSA is also depicted in our own study, as culture specimens cumulatively reached 76% and was 67% among abscesses drained at an author's single institution (APL). Although this study was not able to identify associated risk factors for MRSA within our population, review of patient age at time of intervention suggests that a toddler population, less than 3 years of age, is at greatest risk. Presumably, this finding may be explained by the associated lack of formal toilet training and the use of diapers in this age group that may promote a local environment conducive to bacterial propagation. Standard of care in the treatment of subcutaneous abscesses has been through incision and drainage. Although routine incision, drainage, and debridement of a superficial suppurative process are often adequate for smaller abscesses often treated as outpatients or through an emergency department, abscesses larger than 5 cm often require formal surgical intervention [5,6]. The drainage of these larger
Fig. 4 Isolated organisms from 101 cultured abscesses. MSSA indicates methicillin-sensitive Staphylococcus aureus.
abscesses has often implicated the routine need for dressing changes that consist of classic wound packing and healing by secondary intention. Modifications to this surgical paradigm that opens and/or removes the superficial dermis of the abscess cavity for subsequent wound packing have been described. These modifications include simple large linear incisional drainage without packing, incision with curettage and primary wound closure with antibiotic coverage, or the insertion of a draining Pezzer catheter for wound decompression and healing [7-9]. Each of these published techniques has been exclusively described in adult populations with reported similar outcomes to standard wide incision and drainage, often with reduced pain and time to wound closure. The use of such techniques has remained regionalized. In addition, none of these studies described their use in populations affected with MRSA. The presented technique maintains the surgical paradigm of abscess treatment. The procedure not only allows the surgeon to adequately drain the contained suppurative material, reduce loculations within the subcutaneous tissue, and curette and/or debride the necrotic tissue contained within the abscess but also allows for the ongoing drainage of the wound by the prevention of premature skin annealing. Where the greatest benefit is seen with this technique, however, is in the obviation of the need to routinely pack these often large subcutaneous cavities in affected children. We would also contend that the ability to effectively heal the associated wounds without the need for wound packing reduces treatment noncompliance in this pediatric population. This technique offers both ease of use not only to both the surgeon as either a formal operative technique or one performed under conscious sedation but also to the patient's family as simple wound cleansing and cover dressings are all that is required after drainage.
1566 It is the authors' experience that the described technique has its greatest impact in the treatment of the larger, subcutaneous processes common to extensive MRSA soft tissue infection. Although not formally captured in the retrospective review of our patient population, typical abscesses encountered were greater than 5 cm in greatest diameter. Although the point of origin is often easily identified and occasionally shows evidence of partial decompression of the underlying suppurative process, these large abscesses demonstrate expansive cellulitis with marginal fluctuance to the underlying process, until extensive subcutaneous tissue destruction is present. These complex, often interdigitating, subcutaneous processes, were often best drained with numerous drain placements, to allow for formal drainage and debridement of each loculation. In the presented series, 30% of the patients required more than a single drain placement, to allow for appropriate decompression of the underlying suppurative process. We cannot draw any conclusions from this study on the necessity of postoperative antibiotic treatment in our population of pediatric patients. Despite contemporary publications refuting the routine use of antibiotics after drainage techniques, these publications have often excluded patients with either abscesses greater than 5 cm or with abscesses that manifest a significant degree of associated cellulitis, often seen with MRSA infections [10,11]. Although not standardized in this retrospective review, it was the authors' preference to treat patients preoperatively with parenteral antibiotics and continue parenteral coverage until regression of clinical cellulitis was apparent. Antibiotic coverage was often continued until the time of drain removal, often 7 to 9 days after drainage, with trimethoprim/ sulfamethoxazole coverage. Additional study is needed to determine the actual necessity of postoperative coverage with parenteral or enteral antibiotics in attempts to minimize the inpatient length of stay of these patients, which averaged 1.5 days. Further study is warranted to fully evaluate this procedure's ultimate success in treatment through long-term
A.P. Ladd et al. outcome analysis, as well as its acute impact on morbidity from the implied reduction in pain experienced by these pediatric patients postoperatively. However, as illustrated in the early outcomes from this study, the described technique is safe and effective in a pediatric population with a high prevalence of MRSA, with no reported recurrence of disease or failure to effectively treat, and having the additional benefit of eliminating repetitive wound packing in the treatment of this young population.
References [1] Seal J, Glynn L, Statter M, et al. A high prevalence of methicillinresistant Staphylococcus aureus among surgically drained soft-tissue infections in pediatric patients. Pediatr Surg Int 2006;22:683-7. [2] Faden H, Rose R, Lesse A, et al. Clinical and molecular characteristics of staphylococcal skin abscesses in children. J Pediatr 2007;151:700-3. [3] Herold BD, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593-8. [4] Frank AL, Marcinak JF, Mangat PD, et al. Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children. Pediatr Infect Dis 1999;18:993-1000. [5] O'Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med 2009;16:470-3. [6] Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department—part I. J Emerg Med 1985;3: 227-32. [7] Sorensen CC. Linear incision and curettage vs. deroofing and drainage in subcutaneous abscess. A randomized clinical trial. Acta Chir Scand 1987;153:659-60. [8] Abraham N, Doudle M, Carson P. Open versus closed surgical treatment of abscesses: a controlled clinical trial. Aust N Z J Surg 1997;67:173-6. [9] Philip RS. A simplified method for the incision and drainage of abscesses. Am J Surg 1978;135:721. [10] Hankin A, Everett WW. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med 2007;50:49-51. [11] Lee MC, Rios AM, Fonseca Aten M, et al. Management and outcome of children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2004;23:123-7.