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.

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.

The IDSA guideline–recommended oral antibiotic options for empiric therapy include trimethoprim-sulfamethoxazole, doxycycline or minocycline for older children, or clindamycin, as long as the local community-acquired MRSA clindamycin resistance rate isn’t more than 10%.

The guidelines also include linezolid on the recommended list. However, Dr. Dennehy is opposed to using linezolid as initial therapy for an uncomplicated abscess or cellulitis.

"It’s a very expensive antibiotic. It’s probably pushed hard by some of the drug reps, but it has adverse effects, including hematologic toxicity. We reserve it in the infectious diseases community for infections where we want to transition off of IV vancomycin and need an oral alternative," she explained.

Neither the American Academy of Pediatrics nor any other organization recommends keeping a child with a MRSA skin infection out of school or day care.

"I get this question a lot. If you can cover the lesion and it’s not draining outside of the bandages, that child can go back to school or day care," Dr. Dennehy stressed.

In patients being treated empirically with an antibiotic, therapy should be adjusted once the etiologic organism and its drug susceptibility are known.

"About a third of the skin infections that look like MRSA are really MSSA [methicillin-sensitive S. aureus]. You can treat those orally with a first-generation cephalosporin, like cephalexin. You don’t need to continue on with something that’s directed at MRSA," according to Dr. Dennehy.

Clear discharge instructions are a key element in achieving treatment success. The family needs to understand the importance of hand washing after touching infected skin and the necessity to avoid sharing towels, linens, and other items that have contacted infected skin.

Dr. Dennehy reported having no relevant financial conflicts.

Many Pediatricians Want More I&D Training