MANAGEMENT OF SURGICAL INFECTIONS

21. What is the drug of choice for the treatment of an abscess?

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A knife. Surgically drain the abscess. Abscesses have no circulation of blood within them to deliver an antibiotic. The antibiotic, even if injected directly into the abscess, would be worthless because the abscess contains a soup of dead microorganisms and white blood cells (WBCs). Even if the organisms were barely alive, they would not be reproducing and incorporating the antibiotic. The drug most likely would not work at all at the pH and pKa conditions of the abscess environment.

If there is an indication for an antibiotic, it would be in the circulation around the compressed inflammatory edge of the abscess and the cellulitis (at the vascularized “peel of the orange”) and uncontaminated tissue planes through which the necessary drainage must be carried out. A focal infection is managed by a local treatment, which is both necessary in all abscesses and sufficient treatment in many. Adjunctive systemic antibiotics are occasionally indicated for protection of the tissues through which drainage is carried out. If it helps to make this fundamental surgical principle clear, here is the rule of thumb for management of abscesses: Where there is pus, let there be steel. Perhaps one of the most gratifying procedures in all of medicine is the drainage of pus with immediate relief of local and systemic symptoms (e.g., a perirectal abscess).

22. Which abscess treatment is the important one in determining the outcome of a patient with intraabdominal sepsis?

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It is the drainage of the last abscess that counts. There should be little applause for drainage of a pelvic abscess in the patient who retains a subphrenic abscess. The patient responds dramatically when the last pus is drained.
This has been an area of significant advance in managing surgical infections because noninvasive scanning capability has facilitated the finding of multiple pockets of pus. Furthermore, such modalities as the computed tomography (CT) scan not only find but also percutaneously direct the fixing of the last abscess. What might have been an indication for an exploratory return trip to the operating room only a decade before (i.e., a failing patient on appropriate therapy should trigger the first response, “Where’s the pus?”) is now a good indication for a CT scan to find and drain the focal infection.

23. Which is preferred for draining an intraabdominal abscess, a needle or a knife?

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Which can be done most expeditiously? The patient with intraabdominal sepsis is very ill, and the earliest, safe drainage is the procedure of choice. There may be advantages to the less invasive CT scanning, which can be repeated and has less morbidity if the results are negative. Surgery, on the other hand, can fix associated conditions that may have caused the abscess, such as the devitalized loop of bowel or the leak in the anastomosis that can be exteriorized. Each method is likely to find multiple collections, and each can leave external drains for lavage and continuing drainage. Whether by needle or by knife, the urgency and adequacy of local treatment of focal infection determine which methods takes precedence.

24. What is the role of gallium scintiscanning in early finding of abscesses in the abdomen?

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There is none. Ordering a gallium scan is a temporizing means of self-deception that some progress is being made in finding out what is wrong with the patient. In fact, it merely postpones decisions about intervention in critical illness for several days, often to a point beyond salvage. Gallium scanning involves bowel prepping, a vigorous WBC response from an active bone marrow, and false-positive test results at the sites of tubes and incisions. It is a time-consuming and unreliable test that is the obverse of the principles of early and definitive management. Do not order a gallium scan to satisfy a consultant that “something is being done for this patient.”