Dermatology & HEENT (April 2015)
This month please read the following two articles on management of abscesses and skin infection.
Original research: OMalley et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Academic EM 2009
Review: Fitch et al. Abscess Incision and Drainage. NEJM 2007. Please also watch the associated video.
Refer to the Asynchronous Learning page to see which questions you answer for original research articles vs. reviews. Please submit responses to each article in a unique post.
This month’s AIR module will be HEENT.
25 comments
O’Malley: packing vs no packing
What are some strengths of the study?
prospective, randomized
What are the limitations?
too small to apply to the range of practices/situations
What are the main outcomes of the study?
packing unnecessary, causes pain
Does reading this article change your practice? If so, how?
not really, already don’t pack all abscesses, but do still pack some based on my assessment of pt factors
Fitch et al.
■How has reading the article changed your practice?
no change- I typically use loop drainage or a standard I&D with no packing whereas this article advocates packing the abscess cavity
■What information had you believed in previously that were debunked by reading this article?
NA
■What new information did you learn from reading this article?
NA
■What are current areas of uncertainty on this topic that can be potential areas for research?
Effective analgesia/anesthesia seems to be the most interesting/challenging issue
Omalley et al
■What are some strengths of the study?
good topic/questions dogma
patient centered outcomes measured
■What are the limitations?
all patients treated with antibiotics (without comment of cellulitis)which is not standard practice and abscess were limited to <5cm, which excludes many abscesses. The authors acknowledge these limitations and propose a follow-up study that addresses these among others.
■What are the main outcomes of the study?
pain scores, pain meds used, need for re-exploration of abscess, overall no significant differences between groups
■Does reading this article change your practice? If so, how?
supports my practice of not packing abscesses
O’Malley et al.
It’s really too bad this study required everyone to take antibiotics. It really limits any generalizability.
Also, I’m uncertain if the study was really powered enough to detect differences in the rate of patients requiring intervention. Their CI and p values were huge for the groups. And unfortunately that was their primary outcome.
here’s some more easy-to-digest FOAM background read with some similar studies on packing vs. no packing in peds patients.
http://emlyceum.com/2014/03/31/abscess-answers/
Thank you for your participation everyone.
O’Malley et al.
1. What are some strengths of the study?
Relevant topic, randomized study, topic without extensive prior literature
2. What are the limitations?
Few of the p values reached level of significance. Only pain scores and opioid use were statistically significant, and these were not the primary outcomes. Primary outcomes did not have statistical significance. Also all patients received antibiotics.
3. What are the main outcomes of the study?
Need for intervention at 48 hours. Secondary outcomes were pain and medication use.
4. Does reading this article change your practice? If so, how?
Not really, but I will look forward to additional, larger studies on this topic.
Omalley et al
■What are some strengths of the study?
The topic is definitely relevant to Emergency Medicine, and they had well-defined, patient-centered outcomes with very reproducible methods.
■What are the limitations?
As has already been said, all patients were given antibiotics, which may limit the validity of the results. Also, it seemed like the exclusion criteria were really strict, with regards to the size and location of abscesses, and I think this limits our ability to apply these results to any regular practice.
■What are the main outcomes of the study?
The primary outcome was need for intervention at 48hrs, with secondary outcomes of subjective pain scores, need for pain medications, and evaluation of erythema, induration and fluctuance at 48hrs. They found no difference in need for intervention between the packed and non-packed groups, with higher pain scores and more pain meds needed for the packed group.
■Does reading this article change your practice? If so, how?
This wouldn’t really change my practice, but rather reinforces that most non-complicated abscesses probably do not require packing.
Fitch et al.
■How has reading the article changed your practice?
I found the little picture of skin tension lines interesting – not something I always think about, but definitely useful information.
■What information had you believed in previously that were debunked by reading this article?
They discussed that antibiotics aren’t really necessary in uncomplicated abscesses, but this was not especially new information.
■What new information did you learn from reading this article?
Taking skin tension lines into consideration when performing the incision.
■What are current areas of uncertainty on this topic that can be potential areas for research?
This advocated packing the wound, which is contradictory from the other article, so further research on this topic could be warranted. Adequate pain control during I&Ds also seems like an ongoing issue.
Fitch et al.
1. How has reading the article changed your practice?
Performing I&D on a patient with artificial heart valves due to increased risk of endocarditis from the transient bacteremia. This issue was not something that I had thought about previously.
2. What information had you believed in previously that were debunked by reading this article?
N/A
3. What new information did you learn from reading this article?
I learned about skin-tension lines.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Is there a need for packing at all? loop drainage vs traditional I&D?
What are some strengths of the study?
– They asked a simple, clinically important question. Decent follow-up. Good methods to quantify pain (by VAS and # of pain meds taken). Blinded providers when they re-evaluated a patient’s wound.
What are the limitations?
Small sample size. Non-generalizable patient population. Excluded a lot of patients (sig comorbidities, abscesses, HIV/malignancies, immunosuppressed pts, inability to follow-up, etc.)They got cultures (why!?!) and all patients were given antibiotics.
What are the main outcomes of the study?
-The primary outcome was need for intervention at return visit – 48h after enrollment. They had 67% follow-up at 48 hous. Of those 34 patients, nine (26%) needed an intervention.
– Does reading this article change your practice? If so, how?
This article may change my practice for small, uncomplicated abscesses. I already tell patients that if the packing falls out, that it is not a big deal. Although this paper is only a pilot, it makes a convincing point that packing is both painful and likely has little benefit (in small, uncomplicated abscesses).
Fitch et al.
■How has reading the article changed your practice?
It hasn’t but it was a nice review. I agree with Andrew that I did not think about patients with replacement heart valves and the possibility of bacteremia. They seem to recommend a couple of things that I question after reading the literature (packing the wound & irrigating).
■What information had you believed in previously that were debunked by reading this article?
I liked how they said that antibiotics were NOT required. They were vague about which patients should receive abx.
■What new information did you learn from reading this article?
Topical abx are NOT required after I&D.
■What are current areas of uncertainty on this topic that can be potential areas for research?
Which patients deserve ABx, cost/effectiveness of wound cultures, a larger packing vs. non packing study, finishing our loop study
Omally
Strengths-
Applicable question, simple and easily reproducible protocol, patient perspective
Limitations-
Small sample size, everyone got antibiotics. You could argue that the antibiotics decreased the rate of need for additional procedure rather than packing/no packing. Although another study in peds (Kessler et al 2012 Peds Em Care) without abx had same results but had higher rates of need for secondary procedure in both groups.
Outcomes-
pain scores, need for intervention at 48hrs (change abx, repeat I&D)
Practice change?-
I’ve been moving to loop and skipping the packing if can’t do the loop. I was moving this way prior to reading this.
Fitch
Practice change-
I have been moving away from routine packing.
Debunked-
not a whole lot of new ground here
New info-
I have tried to follow skin tension lines but some abscesses don’t follow skin tension lines and I feel that in these cases I don’t get adequate drainage
Uncertainty?
Maybe looking into outcomes with incision along tension lines vs along the longest axis of abscess
O’Malley
1. Strengths: tried to work towards removing possibly painful experience that patients often experience
2. Limitations: small population size, antibiotics given to everyone, cultures sent on everyone. Use practices that ACEP has come out against routinely using.
3. Outcomes: Higher pain scores for those who were packed
4. Practice changing?: Not really. Would like to see similar study without abx and using ultrasound measurements to assess depth as well as width. Would love to stop packing small abscesses but don’t think this paper pushes me to do so.
Fitch
1. Practice changing: figure about skin incision lines will remind me to keep cosmesis in mind even when making small incisions
2. No debunking information
3. That overpacking thought to risk ischemia to wound edges. Didn’t think one could pack enough gauze to compress nearby vessels.
4. Would be interested in seeing if irrigation of the wound really changes outcomes.
O’Malley et al:
What are some strengths of the study?
– very relevant EM topic. We deal with I&Ds multiple times a shift. — their methods are simple and reproducible.
– I liked how a research study person removed the dressing and the packing beforehand
What are the limitations?
– there are several:
1- they put all people on abx, which I don’t normally do.
2- limited generalizability b/c they looked at a very uncomplicated pt population which is not representative of our pts
3- some loss to follow-up
4- small study, low n
What are the main outcomes of the study?
– need for intervention in 48 hours
– higher pain scores in pts who were packed.
Does reading this article change your practice? If so, how?
– I would entertain the idea of not packing, and irrigating wounds more. currently, I do not irrigate all wounds, I like using suction for many of the larger ones.
O’Malley: packing vs no packing
What are some strengths of the study?
very useful and practical, prospective, randomized, relatively broad range of abscess
What are the limitations?
quite small, do not include other risk factors IVDU, DM, etc and these are often the pts we see
What are the main outcomes of the study?
no difference between packing or no packing
Does reading this article change your practice? If so, how? I have considered this a lot given how painful it seems to pack the abscesses so the more evidence helps me continue to pack fewer abscesses.
Fitch et al.
■How has reading the article changed your practice?
This has been my typical approach although I tend towards loops these days.
■What information had you believed in previously that were debunked by reading this article?
none in particular
■What new information did you learn from reading this article?
I did not realize you can over pack and cause tissue damage, although pt discomfort tends to limit this in my experience.
■What are current areas of uncertainty on this topic that can be potential areas for research?
irrigation vs only exploration
FITCH
Practice change? I will likely use needle aspiration prior to cutting open many of these abscess (esp for culture data during follow up). Additionally, the parallel to skin lines and avoid puncturing the back wall were helpful suggestions.
Debunked? Many providers will give antibiotics to an abscess without signs of erythema, and this may not be necessary.
New? The 0.5 cm size criteria and accessible location are good guidelines, along with surgical consultation for face abscesses.
Research? Sterile procedural technique still seems subject to wide practice variation. Is there an actual difference in outcome/morbidity/readmission/reinfection if I wear blue gloves and a mask vs. draping the area, getting sterile, and wearing a gown?
O’MALLEY
Strengths? Randomization process and single blinding
Limitations? Significant exclusion criteria including many of the groups we treat (HIV, perirectal abscess, immunosuppressed, diabetes, etc.). Overall small sample size
Outcomes? Less pain without significant change in outcome in abscesses drained without packing.
Practice change? Interesting, most abscesses I’ve seen in the ED received packing unless they were <2cm in size. If this reduces pain and has no impact on outcome, I'm happy to pack less.
This is great stuff. The “to pack or not to pack” question is an interesting one and raises some other topics worthy of discussion. What percentage of our “packing” falls out? (I admit that I always struggle with how to pack and secure packing/bandaging in any abscess near the buttocks). Is this the most painful part of the procedure (ie more painful than the actual IandD? Is the putting as much packing as humanly possible into the wound important? Would a small wick be effective?
Keep it coming!
O’Malley
Strengths: good EM topic, randomized, blinded follow up including follow up, study pain as one of their primary outcome
Limitations: small sample size; unclear why pateints were on Abx – would it change outcome? (they recognize this); not a diverse population (also recognized)
Outcomes: people that were packed had more pain
Change your practice: i don’t pack because i saw how much pain it causes patients and this helps show that that is probably better. interesting to see that poor follow up on patients that were NOT packed which shows that it is probably as good and they were healing well – as was seen in calling them later
How has reading the article changed your practice?
Not much; good review. I don’t usually practice sterile technique but they have interesting point about MDR bacteria
What information had you believed in previously that were debunked by reading this article?
none
What new information did you learn from reading this article?
possible ischemia from packing
What are current areas of uncertainty on this topic that can be potential areas for research?
anesthesia for abscess drainage
OMalley
Strengths: Elegant, with very good follow-up. I found it compelling that many of the people who weren’t packed didn’t feel the need to come back at all.
Limitations: Small sample size. Methods out-of-date, e.g., routine antibiotics.
Packing (probably) doesn’t improve abscess outcomes and is more painful.
I probably will pack fewer simple abscesses. I look forward to the follow-up study with more patients (including those with chronic disease and immunosuppression) and no routine antibiotics.
Fitch…
Practice change: Not much; I learned from this article.
Debunked: This didn’t debunk routine antibiotics for me, since I learned from this article. But it does counter the OMalley article in that respect. Worth noting.
New information: I thought more about cultures this time around. We tend not to culture in the ED. But as I look more into the literature, it seems that it’s a problem to “never culture.” I’ve started to culture anyone who receives antibiotics, especially if they get admitted for IV antibiotics. That way, if they fail, we know what else to try.
More research on patients with chronic disease, including HIV. Is the natural history of their abscesses different. Would they benefit from packing vs. no packing, loop vs. traditional etc.
OMalley
Strengths: Prospective, randomized trial with good follow-up. ED population.
Limitations: Sample size, exclusion criteria (many patients we see abscesses in), routine abx
Results: Based on small, carefully selected sample it appears packing doesn’t improve abscess outcomes and increases pain.
Me: This gives me backing for argument that simple abscesses probably don’t always need to be packed. That being said, I also don’t routinely send simple abscesses out with antibiotics if they lack cellulitis or systemic symptoms. As with any treatment, it seems like the discharge instructions and push for good follow up is the most important thing we can do.
Fitch
Changes to my practice: None, this seems like text book, mostly quoting dogma rather than studies
Debunked: NA
New Info: None
Uncertainty/Future research: most of the dogma stated in article – e.g. value of packing, value of abx, approaches to analgesia (field v local v nerve blocks v sedation) and effects on outcome/pain