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Difficulty: MediumInfectious Diseases

A 34-year-old previously healthy man presents to the outpatient clinic complaining of a painful swelling on his right posterior thigh that began 3 days ago. He has no significant past medical history and takes no medications. His temperature is 37.0°C (98.6°F), blood pressure is 122/78 mmHg, pulse is 76/min, and respiratory rate is 14/min. Physical examination reveals a 2.5-cm, exquisitely tender, fluctuant, erythematous nodule. There is less than 1 cm of surrounding erythema and no regional lymphadenopathy. A point-of-care ultrasound confirms a localized fluid collection with no deep tissue tracking. The physician performs an uncomplicated bedside incision and drainage, yielding approximately 10 mL of opaque, yellow purulent material. Which of the following is the most appropriate next step in the management of this patient?

  1. Local wound care without systemic antimicrobial therapyAnswer
  2. B
    A 5-day course of oral cephalexin
  3. C
    A 5-day course of oral trimethoprim-sulfamethoxazole
  4. D
    A 7-day course of oral clindamycin
  5. E
    A single dose of intravenous vancomycin prior to discharge

Answer

Local wound care without systemic antimicrobial therapy is the correct management, as incision and drainage alone is curative for simple abscesses in healthy patients.
The correct management for a mild, purulent skin and soft tissue infection (such as a simple abscess) in an immunocompetent patient without systemic signs of illness (fever, tachycardia, tachypnea) is incision and drainage followed by local wound care. Systemic antimicrobial therapy provides minimal to no additional clinical benefit in this specific population once adequate source control is achieved. Withholding antibiotics in this scenario is a core tenet of antimicrobial stewardship.

Step-by-Step Solution

1
Evaluate the patient's clinical stability and immune status.
The patient is young, previously healthy, and has entirely normal vital signs without systemic inflammatory response syndrome (SIRS).
Determines whether the infection is classified as mild, moderate, or severe.
2
Assess the characteristics of the skin and soft tissue infection (SSTI).
It is a purulent infection (abscess) that is localized (2.5 cm) with minimal surrounding cellulitis.
Differentiates purulent from non-purulent SSTIs, which guides both mechanical and pharmacological management.
3
Apply infectious disease guidelines for mild purulent SSTIs.
Current guidelines recommend incision and drainage alone for simple abscesses in immunocompetent patients without systemic signs.
Ensures appropriate antimicrobial stewardship by avoiding unnecessary antibiotic exposure.

Key Concept

Antimicrobial stewardship in the management of mild, purulent skin and soft tissue infections (simple cutaneous abscesses).
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Topics

Infectious Diseases

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