Infectious Diseases

STEAMBOAT SPRINGS, COLO.  – A surprisingly high percentage of primary care pediatricians don’t routinely use incision and drainage to treat simple boils in accordance with expert consensus clinical care guidelines, according to a national survey.

However, 55% of responding pediatricians indicated they were interested in obtaining further training in abscess management. And the good news for pediatricians lacking ready access to an expert is that a superb instructional training video is available on the Internet to subscribers of the New England Journal of Medicine, Dr. Penelope H. Dennehy said at the meeting.

Dr. Penelope H. Dennehy

The video was created by Dr. Michael T. Fitch and his colleagues at Wake Forest University, Winston-Salem, N.C. and has an accompanying instructional text. Dr. Dennehy is a professor of pediatrics and director of the division of pediatric infectious diseases at Brown University, Providence, R.I.

The Infectious Diseases Society of America (IDSA) guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections released last year (Clin. Infect. Dis. 2011;52:285-92) emphasize that the primary treatment of uncomplicated abscesses and boils is incision and drainage (I&D) alone. There is no need for aspiration and culture, because antibiotics are not warranted as part of initial treatment except in special circumstances. In most cases, I&D alone will be adequate.

Yet a national survey of 385 primary care pediatricians conducted by Dr. Alex R. Kemper and his coworkers at Duke University, Durham, N.C., found that only 59% of respondents would perform I&D in their office for a 3-year-old presenting with an uncomplicated boil or abscess. If the child was 6 months old, 46% would do so. For an 8- or 15-year-old, roughly 68% of pediatricians would treat the skin lesion with I&D (Clin. Pediatr. 2011;50:525-8).

About 10% of respondents indicated they would routinely aspirate the lesion with a needle and syringe.

When pediatricians who don’t use I&D to treat uncomplicated abscesses in their office were asked why not, 10% replied that no one in their practice could do the procedure. Another 34% reported that it’s too time consuming, and 24% indicated they considered reimbursement for I&D insufficient to justify using the treatment.

Fifty-six percent of the pediatricians named trimethoprim-sulfamethoxazole as their initial antibiotic of choice for empiric treatment of uncomplicated abscesses. Eleven percent named clindamycin, and 11% opted for a beta-lactam or cephalosporin. But 18% of pediatricians said they would go with various dual therapies, which is not recommended in the IDSA guidelines.

The guidelines recommend culturing and empiric antibiotics after I&D of an abscess in specific situations. These include the patient with signs and symptoms of systemic illness; immunosuppression; rapid local progression with associated cellulitis; or extensive disease, such as a large area of redness around the initial abscess. Culturing and antibiotics also are recommended in very young infants with a simple abscess, in patients with associated septic phlebitis, in those whose abscess can’t be drained completely, and in patients who haven’t responded adequately to I&D alone.

02/15/12  

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EXPERT ANALYSIS FROM A MEETING ON PRACTICAL PEDIATRICS SPONSORED BY THE AMERICAN ACADEMY OF PEDIATRICS

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