One of this blog’s readers, Dr. McLeod, asked the following:
My question is: Does one need to prescribe antibiotics after I+Ding an abscess? I use to work at a county hospital in Oakland, California where there was a high MRSA rate. At that time (2005), we were being taught not it is unneccessary to prescribe antibiotics after I+Ding an abscess, other than to practice defensive medicine. But, is it necessary to prescribe antibiotic in your opinion after an abscess I+D? I am talking about a classic abscess, not a cellulitis of any form.
This is an excellent question that allows me to go off in two directions. First, to directly answer Dr. McLeod’s question, NO, the evidence is fairly strong that I&D of an abscess of <5cm in diameter without concomitant antibiotic therapy is considered adequate and appropriate therapy for an MRSA abscess. For one of the first studies that really showed this, and the one that was probably quoted by the folks with whom you worked in 2005, I direct you to the 2004 paper by Lee et.al in the Pediatric Infectious Disease Journal (PubMed link: http://www.ncbi.nlm.nih.gov/pubmed/14872177)
The 2nd direction or “tangent” I want to explore with this entry has more to do with the follow up of this type of patient, or for that matter any infection patient. The question is “How long do you need to continue antibiotic therapy?”
A few years ago I was sitting in on a lecture at the annual meeting of the Infectious Diseases Society of America. Unfortunately, I can’t remember the speaker in order to give appropriate credit but what has stuck with me ever since is the concept he proposed: Why do we continue to routinely give 10-14 day prescriptions of antibiotics when the infection may be clinically cured in 2-3 days? Rather we should consider the concept of giving the patient antibiotics until clinically better and then for only another 2-3 days an idea that can be called “Better Plus 2”.
Think about this…you automatically give someone a 7, 10, 14 day Rx for an antibiotic. What do you tell them as you hand them the script? “Make sure you take it until it is all finished”. Heck, it even says it right on the bottle the patient receives from the pharmacy! WHY? Because we have been taught that is the way to prevent resistance development. Now, let’s look at the patient proposed by Dr. McLeod above. You I&D that abscess AND give antibiotics for 10 days solely because this is what you have been taught or you want to practice defensive medicine, or whatever reason. You see the patient back on Day 3 and the wound looks great. The abscess and any surrounding cellulitis are gone BUT the patient still has 7 days of antibiotic to go; an antibiotic that is not medically necessary because the patient is clinically cured. Think about it; how do we develop antibiotic resistance? By giving an antibiotic when it isn’t necessary! Is this a greater risk than stopping the antibiotic too early, I would venture an opinion that, yes, it is.
As you know from reading my posts, I am a believer in backing up what I write about with literature/science. Before writing this entry I tried to find some substantiation for this concept in the literature. On my cursory PubMed search nothing came up. It may or may not be out there and I just could not find it. If anyone is familiar with support for this concept please let me know. It is just one of those ideas that make perfect sense to me. There is nothing of which I am aware supporting the routine use of 10-14 days of antibiotics, at least in skin and skin structure infections, so why should Better Plus 2 be any less valid or legitimate? I wanted to throw this out for you to ponder the next time you write that rote duration on your antibiotic Rx.