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Cellulitis and skin abscess in adults: Treatment
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Cellulitis and skin abscess in adults: Treatment
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Literature review current through: Oct 2017. | This topic last updated: Sep 25, 2017.

INTRODUCTION — Patients with skin and soft tissue infection may present with cellulitis, abscess, or both [1-3].

Treatment of cellulitis and skin abscess are reviewed here. Issues related to clinical manifestations and diagnosis of cellulitis and abscess are discussed separately. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis".)

Issues related to skin and soft tissue infections associated with specific epidemiologic factors (such as diabetes, animal bites, and water exposure) are discussed separately. (See "Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities" and "Soft tissue infections following water exposure" and "Soft tissue infections due to dog and cat bites" and "Soft tissue infections due to human bites".)

Issues related to infection involving the gluteal area and perineum are discussed separately. (See "Perianal and perirectal abscess" and "Intergluteal pilonidal disease: Clinical manifestations and diagnosis".)

GENERAL PRINCIPLES — The approach to management of skin and soft tissue infection depends on the nature of the clinical presentation:

Patients with nonpurulent infection (ie, cellulitis or erysipelas in the absence of abscess or purulent drainage) should be managed with empiric antibiotic therapy (algorithm 1). (See 'Nonpurulent infection' below.)

Patients with drainable abscess should undergo incision and drainage; the technique is discussed separately (see "Technique of incision and drainage for skin abscess"). In addition, antibiotic therapy is warranted if clinical criteria are met, as discussed below (algorithm 2). (See 'Drainable abscess present' below.)

Patients with purulent cellulitis (ie, cellulitis associated with purulent drainage in the absence of drainable abscess) should be managed with antibiotic therapy (algorithm 2). (See 'Purulent cellulitis (no drainable abscess)' below.)

Issues related to choosing between oral and parenteral therapy are discussed below. (See 'Oral versus parenteral therapy' below.)

Attention to antibiotic dosing is important, particularly in obese individuals; underdosing in obese patients (particularly those with morbid obesity and lymphedema) may result in higher rates of treatment failure [4].

The approach to empiric antimicrobial therapy should be modified as indicated in the setting of known pathogens, underlying conditions (such as diabetes), and special circumstances (such as animal bites and water exposure). Management of patients in these settings is discussed in detail separately. (See "Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities" and "Soft tissue infections due to dog and cat bites" and "Clinical manifestations and initial management of animal and human bites" and "Soft tissue infections following water exposure".)

Other components of management include elevation of the affected area and treatment of underlying conditions (such as edema or underlying cutaneous disorders) if present [2]. Elevation facilitates gravity drainage of edema and inflammatory substances. The skin should be sufficiently hydrated to avoid dryness and cracking without interdigital maceration.

Oral versus parenteral therapy — Patients with mild infection may be treated with oral antibiotics. Treatment with parenteral antibiotics is warranted in the following circumstances:

Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

Rapid progression of erythema

Progression of clinical findings after 48 hours of oral antibiotic therapy

Inability to tolerate oral therapy

Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular graft)

The decision to initiate parenteral therapy should be based on individual clinical circumstances such as severity of clinical presentation and patient comorbidities. As an example, the presence of an immunocompromising condition (such as neutropenia, recent organ transplant, advanced HIV infection, B cell or T cell deficiency, or use of immunosuppressive agents) should lower the threshold for parenteral therapy.

CLINICAL APPROACH

Nonpurulent infection — Forms of nonpurulent skin and soft tissue infection include cellulitis and erysipelas. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis", section on 'Cellulitis and erysipelas'.)

Management of cellulitis and erysipelas should include elevation of the affected area and treatment of underlying conditions. Elevation facilitates gravity drainage of edema and inflammatory substances. The skin should be sufficiently hydrated to avoid dryness and cracking without interdigital maceration.

Many patients with cellulitis have underlying conditions that predispose them to developing recurrent cellulitis (these include tinea pedis, lymphedema, and chronic venous insufficiency). In such patients, treatment should be directed at both the infection and the predisposing condition if modifiable. As an example, patients with edema may benefit from treatment with compressive stockings and diuretic therapy.

Cellulitis — Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or exudate and no associated abscess) should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) [1-3]. Common options are cefazolin for intravenous therapy and cephalexin for oral therapy; options and doses are summarized in the algorithm (algorithm 1). Issues related to choosing between oral and parenteral therapy are discussed above. (See 'Oral versus parenteral therapy' above.)

This approach is supported by the following studies:

A randomized trial including 496 patients with nonpurulent cellulitis (in the modified intention-to-treat analysis) noted similar clinical cure rates among those treated with cephalexin plus placebo (for empiric treatment of beta-hemolytic streptococci and MSSA; 69 percent) and those treated with cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX; for empiric treatment of beta-hemolytic streptococci and methicillin-resistant S. aureus [MRSA]; 76 percent; difference 7.3 percent; 95% CI -1.0 to 15.5 percent; p=0.09) [5]. While these findings raise the possibility that addition of TMP-SMX may be somewhat superior to cephalexin alone, the results were likely skewed by a relatively large number of patients who did not complete the full course of therapy.

A randomized trial including 153 patients with cellulitis without abscess noted comparable cure rates among those treated with cephalexin (for empiric treatment of beta-hemolytic streptococci and MSSA; 82 percent) and those treated with cephalexin and TMP-SMX (for empiric MRSA coverage; 85 percent) [6].

Additional empiric coverage for MRSA is warranted in the following circumstances [2,7-10]:

Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

Prior episode of MRSA infection or known MRSA colonization

Lack of clinical response to antibiotic regimen that does not include activity against MRSA

Presence of risk factor(s) for MRSA infection (including recent hospitalization, residence in a long-term care facility, recent facility, recent surgery, hemodialysis, and HIV infection)

Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular graft)

Issues related to treatment of MRSA infection are discuss further below. (See 'Approach to antibiotic therapy' below.)

A deepening of erythema may be observed following initiation of antimicrobial therapy. This may be due to destruction of pathogens that release enzymes increasing local inflammation and should not be mistaken for therapeutic failure.

Patients with cellulitis typically have symptomatic improvement within 24 to 48 hours of beginning antimicrobial therapy, although visible improvement of clinical manifestations may take up to 72 hours. Persistence of erythema and/or systemic symptoms after this period of time should prompt consideration of resistant pathogens or alternative diagnoses. In such cases, culture data should be reviewed carefully, pursuit of radiographic evaluation for deeper infection is appropriate, and broadening antibiotic therapy to include coverage for gram-negative bacilli pending further diagnostic data is reasonable. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

The duration of therapy should be individualized depending on clinical response. In general, 5 days of therapy is appropriate for patients with uncomplicated cellulitis whose infection has improved within this time period [2,11]. Extension of the duration (up to 14 days) may be warranted in the setting of severe infection, slow response to therapy, or immunosuppression.

In one study including 216 patients hospitalized with nonpurulent cellulitis, 90 percent of patients had improvement in clinical findings and serum C-reactive protein concentration 3 days after initiation of antimicrobial therapy [12,13]. More than half of patients had residual inflammation at the end of therapy (median 11 to 15 days), but relapse occurred in only 16 percent of these cases.

Erysipelas — Patients with erysipelas should be managed with empiric therapy for infection due to beta-hemolytic streptococci.

Patients with systemic manifestations (such as fever and chills) should be treated with parenteral therapy. Appropriate choices include cefazolin, ceftriaxone, or flucloxacillin (algorithm 1). Cefazolin has activity against streptococci as well as MSSA, which is useful in settings where erysipelas cannot be reliably distinguished from cellulitis. Ceftriaxone has activity against streptococci (and may be used for activity against MSSA in some circumstances), and its once-daily dosing allows for convenient outpatient administration.

Patients with mild infection or those who have improved following initial treatment with parenteral antibiotic therapy may be treated with oral penicillin or amoxicillin (algorithm 1). In the setting of beta-lactam allergy, cephalexin (if the patient can tolerate cephalosporins), clindamycin, or linezolid may be used [2]. Macrolides (such as erythromycin) may not be adequate in areas with relatively high resistance rates among beta-hemolytic streptococci [2,14].

The duration of therapy should be individualized depending on clinical response; 5 to 14 days is usually appropriate.

Recurrent infection — Recurrent cellulitis is common; 22 to 49 percent of patients with cellulitis report at least one prior episode [3]. Recurrences occur in approximately 14 percent of cellulitis cases within one year and 45 percent of cases within three years, usually in the same location [3]. Underlying conditions that predispose to recurrent cellulitis include [15-23]:

Edema due to impaired lymphatic drainage

Venous insufficiency

Obesity

Immunosuppression

Fissuring or maceration of the interdigital toe spaces

Tinea pedis

Management of recurrent infection includes careful evaluation to rule out alternative diagnoses. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis", section on 'Differential diagnosis'.)

The approach to treatment of a recurrent episode is the same as the approach for an initial episode. In addition, predisposing condition(s) should be identified and alleviated if possible [3]. As an example, patients with edema may benefit from treatment with compressive stockings and diuretic therapy. (See "Clinical staging and conservative management of peripheral lymphedema" and "Medical management of lower extremity chronic venous disease" and "Dermatophyte (tinea) infections".)

For patients with recurrent infection due to S. aureus, attempting decolonization is reasonable; this is discussed further separately. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and control", section on 'Decolonization' and "Methicillin-resistant Staphylococcus aureus in children: Prevention and control".)

Suppressive antibiotic therapy may be warranted for patients with three to four episodes of cellulitis per year in the setting of predisposing factors that cannot be alleviated, for as long as the predisposing factors persist [2]. Serologic testing for beta-hemolytic streptococci may be a useful diagnostic tool to help guide the choice of suppressive antibiotic therapy. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Antibiotic options for suppressive therapy include:

For patients with known or presumed beta-hemolytic streptococcal infection [24,25]:

Penicillin V (250 to 500 mg orally twice daily)

Erythromycin (250 mg orally twice daily)

Penicillin G benzathine intramuscular injections (1.2 million units for patients who weigh >27 kg; 600,000 units for patients who weigh ≤27 kg) administered every two to four weeks

For patients with known or presumed staphylococcal infection [26]:

Clindamycin (150 mg orally once daily)

Trimethoprim-sulfamethoxazole (one double-strength tablet orally twice daily)

Suppressive therapy may be continued for several months with interval assessments for efficacy and tolerance. If recurrent cellulitis occurs, the patient should be reevaluated promptly; patients may be given instructions to self-initiate antibiotic therapy at onset of symptoms prior to seeking immediate medical attention.

Support for suppressive antibiotic therapy for prevention of recurrent infection comes from the following studies:

In a study of 209 cases of cellulitis, recurrences were observed in 17 percent of patients; among 143 patients with erysipelas, 29 percent had recurrent infection [15,27]. Early episodes of cellulitis cause lymphatic inflammation, and repeated infection can lead to lymphedema. Supportive care with elevation of the affected area and treatment of underlying predisposing conditions are paramount. (See "Clinical staging and conservative management of peripheral lymphedema".)

In a systematic review and meta-analysis of five trials with a total of over 500 patients with at least one prior episode of cellulitis, prophylactic antibiotic use reduced the risk of subsequent cellulitis (relative risk [RR] 0.46, 95% CI 0.26-0.79) [28]. Findings from two of the included studies also demonstrated that antibiotic prophylaxis is cost-effective [29].

In a subsequent randomized trial that included 274 patients with two or more episodes of lower extremity cellulitis, penicillin (250 mg orally twice daily) nearly halved the risk of recurrence during 12 months of prophylaxis (hazard ratio 0.55; 95% CI 0.35 to 0.86; p = 0.01), but the protective effect diminished rapidly after the prophylaxis period ended [24]. A lower likelihood of response was observed among patients with a body mass index ≥33, multiple previous episodes of cellulitis, or lymphedema of the leg. These findings warrant further investigation since patients in these categories are most likely to receive long-term prophylaxis.

Purulent infection — Purulent infection refers to presence of a drainable abscess or cellulitis associated with purulent drainage (in the absence of drainable abscess) (algorithm 2). An infection involving purulence (whether the process began as an abscess [with secondary cellulitis] or as a cellulitis [with secondary purulence]) is potentially attributable to S. aureus, which should be reflected in the choice of empiric antimicrobial therapy.

Drainable abscess present — Patients with drainable abscess should undergo incision and drainage (algorithm 2) [30,31]. The technique for incision and drainage and the role of culture are discussed separately. (See "Technique of incision and drainage for skin abscess".)

Individuals at risk for endocarditis warrant empiric antibiotic therapy prior to incision and drainage; an oral antibiotic with activity against MRSA and beta-hemolytic Streptococcus should be administered one hour prior to procedure (algorithm 2) [32,33]. (See "Antimicrobial prophylaxis for the prevention of bacterial endocarditis".)

Role of antibiotic therapy — For patients undergoing incision and drainage of a skin abscess, we suggest antibiotic treatment. In particular, we favor antibiotic treatment for patients with any of the following:

Single abscess ≥2 cm [34,35]

Multiple lesions

Extensive surrounding cellulitis

Associated immunosuppression or other comorbidities

Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

Inadequate clinical response to incision and drainage alone

Presence of an indwelling medical device (such as prosthetic joint, vascular graft, or pacemaker)

High risk for adverse outcomes with endocarditis (these include a history of infective endocarditis, presence of prosthetic valve or prosthetic perivalvular material, unrepaired congenital heart defect, or valvular dysfunction in a transplanted heart)

High risk for transmission of S. aureus to others (such as in athletes or military personnel)

However, because many abscesses can be treated successfully with incision and drainage alone, expert opinion varies, and it is reasonable to forgo antibiotic therapy in otherwise healthy patients who have small abscesses (eg, <2 cm) and none of the above factors [36-38]. An antibiotic-sparing approach may be particularly compelling in patients who have multiple antibiotic allergies or intolerances.

The 2014 Infectious Diseases Society of America (IDSA) guidelines on the management of skin and soft tissue infections did not recommend routine antibiotic therapy for patients with mild skin abscesses in the absence of systemic infection, immunocompromising conditions, extremes of age, or multiple abscess, based on earlier data that suggested similar cure rates with incision and drainage alone [2]. However, subsequent large trials have indicated a benefit to antibiotic therapy, even in patients with small abscesses:

In a randomized trial including 1220 patients >12 years of age (median 35 years) with abscess 2 to 5 cm in diameter who underwent incision and drainage, treatment with TMP-SMX (320 mg/1600 mg twice daily) resulted in higher cure rates 7 to 14 days after treatment than placebo (80.5 versus 73.6 percent) [34]. Wound cultures were positive for MRSA in 45 percent of cases.

In another randomized trial including more than 780 patients with skin abscess ≤5 cm (45 percent were ≤2 cm) who underwent incision and drainage, treatment with TMP-SMX or clindamycin each resulted in higher cure rates at 10 days than placebo (82 or 83 percent versus 69 percent) [35]. MRSA was isolated in 49 percent of cases.

Antimicrobial therapy may also decrease the risk of recurrent skin abscess. In one randomized trial, new infections at one month of follow-up were less common among those who received clindamycin than those who received TMP-SMX or placebo [35]. In another randomized trial, the likelihood of recurrent abscess formation was lower in patients who received TMP-SMX than in patients who received placebo [38].

The approach to empiric antibiotic selection and duration of therapy is as described below. (See 'Approach to antibiotic therapy' below.)

Purulent cellulitis (no drainable abscess) — Patients with cellulitis associated with purulent drainage (in the absence of drainable abscess) should be managed with antibiotic therapy (algorithm 2). The approach to empiric antibiotic selection and duration of therapy is as described below. (See 'Approach to antibiotic therapy' below.)

Approach to antibiotic therapy — The approach to empiric antibiotic selection is the same for all patients with purulent infection, including:

Patients with drainable abscess and relevant clinical criteria (see 'Role of antibiotic therapy' above)

Patients with cellulitis and associated purulent drainage, in the absence of a drainable abscess (see 'Purulent cellulitis (no drainable abscess)' above)

It is useful to document the baseline appearance of the physical findings at the start of antibiotic therapy. A baseline digital image should be taken to monitor progress.

Pathogens to cover — Patients with purulent infection (as defined in the preceding section) should be managed with empiric therapy for infection due to MRSA, pending culture results (algorithm 2) [1,2]. Empiric therapy for infection due to beta-hemolytic streptococci is usually not necessary. Empiric therapy selection should be tailored to culture and susceptibility results when available.

This approach is supported by findings of a study including 422 patients with purulent soft tissue infection in which MRSA was the dominant organism (isolated from 59 percent of patients), followed by MSSA (isolated from 17 percent of patients); beta-hemolytic streptococci accounted for a much smaller proportion of these infections (2.6 percent) [39].

Initial management of patients with purulent infection in association with a pressure ulcer, a perioral or peri-rectal site of infection, or prominent skin necrosis consists of antimicrobial therapy that includes empiric coverage for MRSA as well as gram-negative and anaerobic organisms (pending culture and susceptibility results) (algorithm 2).

Choosing an antibiotic agent — Issues related to choosing between oral and parenteral therapy are discussed above. (See 'Oral versus parenteral therapy' above.)

Options for empiric oral therapy of purulent infection (ie, with activity against MRSA) include clindamycin, trimethoprim-sulfamethoxazole, or tetracyclines (doxycycline or minocycline) (table 1 and algorithm 2). The efficacy of clindamycin and TMP-SMX for treatment of uncomplicated skin infection may be considered comparable; this was illustrated in a randomized trial that included 524 patients with uncomplicated skin infections, including both cellulitis and abscesses (cure rates for clindamycin and TMP-SMX were 80 and 78 percent, respectively) [40]. For oral anti-MRSA coverage, we generally favor TMP-SMX, doxycycline, or minocycline; clindamycin is associated with greater risk of Clostridium difficile infection.

Oxazolidinones (linezolid or tedizolid) and delafloxacin are additional agents with activity against MRSA; they should be reserved for circumstances in which none of the other regimens listed can be used, and careful monitoring is required. (See "Pharmacology of antimicrobial agents for treatment of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus".)

For patients who are at high risk of an adverse outcome if infective endocarditis occurs (eg, individuals with prior infective endocarditis, prosthetic heart material, unrepaired congenital heart defect, and valvular dysfunction in a transplanted heart), we favor covering beta-hemolytic streptococci in addition to MRSA pending culture data because of the possibility (albeit small) of streptococcal involvement. This can most conveniently be achieved with clindamycin monotherapy, although the convenience should be weighed against the potential for adverse effects. Because of uncertain streptococcal coverage with TMP-SMX, doxycycline, or minocycline, we add amoxicillin to each of these agents to ensure adequate antistreptococcal activity, although it is not certain that this is necessary [41]. In such patients who are undergoing incision and drainage, antibiotics should be administered 60 minutes prior to the incision.

Options for empiric parenteral therapy of MRSA include vancomycin and daptomycin (algorithm 2); alternative parenteral agents with activity against MRSA are summarized in the table (table 2) and are discussed in detail separately. These agents also have activity against beta-hemolytic Streptococcus. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections", section on 'Parenteral antibiotic therapy' and "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive infections", section on 'Treatment approach'.)

Duration of therapy — The appropriate duration of therapy for treatment of skin and soft tissue infection depends on the nature of the clinical presentation, and the clinical response should guide duration of therapy.

Patients with mild infection who warrant outpatient management with oral antibiotic therapy should have repeat evaluation after 24 to 48 hours to verify clinical response [2]. Patients with MRSA responsive to oral therapy are typically treated for 5 days; extension of the duration (up to 14 days) may be warranted in the setting of severe infection, slow response to therapy, or immunosuppression. Lack of response may be due to infection with resistant organism(s), inadequate adherence, or presence of a deeper, more serious infection than previously realized.

Patients with infection warranting parenteral therapy (in the absence of bacteremia or involvement beyond soft tissue) are typically treated for a total duration of 5 to 14 days. Once there are signs of clinical improvement with no evidence of systemic toxicity, antibiotics may be transitioned from parenteral to oral therapy.

For patients with abscess that was detected radiographically, follow-up imaging may be useful for assessing response to therapy. (See "Cellulitis and skin abscess: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Recurrent infection — The approach to management of recurrent purulent cellulitis is the same as the approach to management of the initial episode.

A recurrent abscess at a site of previous infection should prompt consideration of additional causes such as pilonidal cyst, hidradenitis suppurativa, or presence of foreign material [2]. Surgical exploration and debridement may be warranted, and suppressive antibiotics may be reasonable if no drainable collection or treatable underlying condition is found. In patients with recurrent abscess beginning in early childhood, evaluation for a neutrophil disorder is warranted. (See "Primary disorders of phagocytic function: An overview".)

For patients with recurrent infection due to S. aureus, attempting decolonization is reasonable; this is discussed separately. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and control", section on 'Decolonization' and "Methicillin-resistant Staphylococcus aureus in children: Prevention and control".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Skin and soft tissue infections".)

SUMMARY AND RECOMMENDATIONS

Patients with skin and soft tissue infection may present with cellulitis, abscess, or both. The approach to management depends on the nature of the clinical presentation. (See 'General principles' above.)

In general, patients with mild infection may be treated with an oral antibiotic regimen. The decision to initiate parenteral antibiotic therapy should be based on individual clinical circumstances such as severity of clinical presentation and patient comorbidities. We recommend that patients with signs of systemic toxicity or rapid progression of erythema be treated initially with parenteral antibiotics (Grade 1B). Parenteral therapy is also appropriate for patients with persistence or progression of symptoms despite 48 hours of oral antibiotic therapy, inability to tolerate oral therapy, or proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular graft). (See 'Oral versus parenteral therapy' above.)

The management of patients with nonpurulent infection (ie, cellulitis or erysipelas in the absence of abscess or purulent drainage) consists of antibiotic therapy (algorithm 1). (See 'Nonpurulent infection' above.)

Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or exudate and no associated abscess) should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA); additional empiric coverage for methicillin-resistant S. aureus (MRSA) is warranted in the circumstances summarized above (algorithm 1). (See 'Cellulitis' above.)

Patients with erysipelas should be managed with empiric therapy for infection due to beta-hemolytic streptococci. (See 'Erysipelas' above.)

The duration of antibiotic therapy for treatment of nonpurulent infection should be individualized depending on clinical response. In general, 5 days of therapy is appropriate for patients with uncomplicated infection who have improved within this time period. Extension of the duration (up to 14 days) may be warranted in the setting of severe infection and/or slow response to therapy.

For patients with recurrent nonpurulent cellulitis, we suggest administration of suppressive antibiotic therapy (Grade 2B). Predisposing factors that can be alleviated should be addressed whenever possible. (See 'Recurrent infection' above.)

The management of patients with purulent infection depends on whether a drainable abscess is present (see 'Purulent infection' above):

Patients with drainable abscess should undergo incision and drainage (algorithm 2). (See 'Drainable abscess present' above and "Technique of incision and drainage for skin abscess".)

The role of antimicrobial therapy in the setting of drainable abscess depends on individual clinical circumstances.

-In general, we recommend antibiotic therapy for patients with multiple lesions, extensive surrounding cellulitis, associated comorbidities or immunosuppression, signs of systemic infection, or inadequate clinical response to incision and drainage alone (Grade 1B), and we suggest antibiotic therapy for patients with skin abscess ≥2 cm (Grade 2A), an indwelling device, or high risk for transmission of S. aureus to others (Grade 2B). (See 'Role of antibiotic therapy' above.)

-For otherwise healthy patients with no risk factors, we suggest administering antimicrobial therapy (Grade 2C). However, because many abscesses can be treated successfully with incision and drainage alone, expert opinion varies, and it is reasonable to forgo antibiotic therapy in otherwise healthy patients who have small (eg, <2 cm) abscesses and none of the above factors. (See 'Role of antibiotic therapy' above.)

Patients with purulent cellulitis (ie, cellulitis associated with purulent drainage in the absence of drainable abscess) should be managed with antibiotic therapy (algorithm 2). (See 'Purulent cellulitis (no drainable abscess)' above.)

Initial treatment for patients with purulent infection who warrant antibiotic therapy should consist of treatment for MRSA (pending culture and susceptibility results) (algorithm 2). In addition, initial treatment of patients with purulent infection in association with a pressure ulcer, a perioral or peri-rectal site of infection, or prominent skin necrosis should consist of antimicrobial therapy that includes empiric coverage for gram-negative and anaerobic organisms (pending culture and susceptibility results). The duration of therapy should be individualized depending on clinical response. (See 'Approach to antibiotic therapy' above.)

The duration of antibiotic therapy for treatment of purulent infection should be individualized depending on clinical response. Patients with MRSA responsive to oral therapy are typically treated for 5 days; extension of the duration (up to 14 days) may be warranted in the setting of severe infection, slow response to therapy, or immunosuppression. Patients with infection warranting parenteral therapy (in the absence of bacteremia or involvement beyond soft tissue) are typically treated for a total duration of 5 to 14 days. Once there are signs of clinical improvement with no evidence of systemic toxicity, antibiotics may be transitioned from parenteral to oral therapy. (See 'Duration of therapy' above.)

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