›Examination under anesthesia is gold standard for intolerant patients
›Antibiotic indications — NOT routine for uncomplicated abscess in healthy patients
›Antibiotics do not replace drainage and should not delay it
›Indications for antibiotic use
›Surrounding cellulitis beyond abscess margin
›Systemic infection signs (fever, tachycardia, leukocytosis)
›Immunosuppression (HIV, chemotherapy, transplant)
›Diabetes mellitus
›Prosthetic valves or devices
›ASCRS guidelines support selective antibiotic use in these scenarios
›Outpatient antibiotic regimens
›Ciprofloxacin 500 mg PO twice daily plus metronidazole 500 mg PO three times daily
›Duration 7-10 days
›Studied for fistula prevention (OR 0.64, though evidence conflicting)
›Metronidazole covers anaerobes
›TMP-SMX DS PO twice daily if MRSA concern
›Duration 7-10 days
›Covers community-acquired MRSA
›Clindamycin 300-450 mg PO every 6-8 hours for MRSA concern
›Check local MRSA sensitivity patterns
›Counsel on Clostridioides difficile risk
›Inpatient IV antibiotic regimens
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›For systemic sepsis, deep abscess, or complex infection
›Broad gram-negative, gram-positive, and anaerobic coverage
›Renally adjust if GFR < 40 ml/min
›Piperacillin-tazobactam plus vancomycin loading dose 25-30 mg/kg IV
›MRSA risk: healthcare-associated, prior MRSA, injection drug use
›Target AUC/MIC monitoring per institution
›Fournier's gangrene regimen
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Plus vancomycin 25-30 mg/kg IV loading
›Plus metronidazole 500 mg IV every 8 hours
›Consider adding antifungal (micafungin 100 mg IV daily) if immunosuppressed
›Antibiotic duration
›Cellulitis and mild infection: 5-7 days
›Systemic sepsis: 7-14 days guided by clinical response
›Fournier's gangrene: Continue until serial debridements complete and systemic signs resolved
›Pain management
›Scheduled NSAIDs and acetaminophen as first line
›Ibuprofen 400-600 mg PO every 6-8 hours with food
›Acetaminophen 650-1000 mg PO every 6-8 hours (max 4 g/day)
›Short-course opioids for severe pain post-procedure
›Oxycodone 5-10 mg PO every 4-6 hours PRN
›Minimize duration; prescribe stool softener concurrently
›Topical lidocaine gel for wound pain during dressing changes
›Sitz baths 2-3 times daily for comfort and wound hygiene
›Wound care regimen
›Sitz baths 2-3 times daily
›Warm water, 10-15 minutes per session
›Promotes drainage and hygiene
›Dressing changes daily or when soiled
›Simple gauze dressing
›No packing in most cases per current evidence
›Stool softeners
›Docusate sodium 100-200 mg PO twice daily
›Reduces straining and pain with bowel movements
›High-fiber diet and adequate hydration
›Prevents constipation and straining
Fournier's gangrene surgical management
›Necrotizing fasciitis operative approach
›Emergent surgical debridement
›Wide excision of all necrotic tissue
›Serial debridements at 24-48 hour intervals until clean margins
›Diverting colostomy consideration
›Extensive perineal involvement
›Facilitates wound management
›ICU care post-operatively
›Hemodynamic support, ventilatory management if needed
›Hyperbaric oxygen therapy
›Adjunct in selected centers; evidence for survival benefit limited