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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

The Practice of Surgical Doctors toward Cutaneous


Abscess Drainage in Khartoum and Bahri
Localities Teaching Hospitals
Nizar Ismail1a, Saifaldawlla Musa2a, Kareemaldin Elsamani3a, Amro Mohamed4a, Abubakir Abd Elmonem Elhaj 5a, Mounkaila
Noma6a, Mogadam BE Mogadam7*, Mohammed Hamad8, Amin Ahmed9, Muneeb Adam10, Seddig Ali11, Alamin Mohamed12,
Mohammed Ismail13
1
Trauma and Orthopedics Department, Buckinghamshire NHS Trust, Buckinghamshire, UK.
2
University of Medical Sciences and Technology, Khartoum, Sudan.
3
General Surgery Department, Peterborough City Hospital, Peterborough, UK.
4
Elite Pharma, Khartoum, Sudan.
5
Pharmaceutical Department, International University of Africa, Khartoum, Sudan.
6
Research Methodology and Biostatistics department, University of Medical Sciences and Technology, Khartoum, Sudan.
7
Microbiology Department, University of Al-Butana, Gezira, Sudan.
8
Medicine Department, Flushing Hospital Medical Center, New York, USA.
9
Heart Failure clinic, Cardiology Department, Ahmed Gasim Hospital, Khartoum, Sudan.
10
Emergency Department, Association Specialized Hospital, Khartoum, Sudan.
11
Health Insurance, Sharg Darfur State, Sudan.
12
Emergency Department, Ribat University Hospital, Khartoum, Sudan.
13
Anatomy Department, Elrazi University, Khartoum, Sudan.

Abstract: cutaneous abscess patients and most of them


prescribing Augmentin. Only 51.2% were following
 Background: daily dressing manner for abscess patients.
Cutaneous abscesses are infections of the skin and
soft tissue, usually caused by the Staphylococcus aureus  Conclusions:
organisms. The study aimed to describe the patterns of Study participants showed different patterns of
doctor’s practice toward cutaneous abscess practice in cutaneous abscess management, senior
management. instructions determined the majority practice and
routine prescription of postoperative antibiotics was one
 Methods: of the most important negative findings of the study.
A facility descriptive Cross-sectional base study Important details of cutaneous abscess management
conducted among the doctors of the surgery emergency were not covered in the guidelines including anesthesia,
departments of five teaching hospitals in Khartoum and operative details and dressing patterns.
Bahri localities that perform emergency operations for
superficial cutaneous abscesses, Total coverage of the Keywords:- Cutaneous abscess, Khartoum, Bahri, Practice,
study population data collected through predesigned management.
questionnaires that included different variables
representing the medical history, physical examination, I. INTRODUCTION
investigation and treatment of cutaneous abscess.
Cutaneous abscesses are infections of the skin and soft
 Results: tissue, presenting as painful, tender, and fluctuant red
Out of 127 participants included in the study from nodules, owing to the host immune response acting to
5 hospitals, with mean age of 26.66 years and mean of isolate the infection from its surroundings. Cutaneous
months surgical experience 19.2. Out of 24.4% of the abscesses are typically polymicrobial, containing bacteria
participants were provided by the hospital protocol of that constitute the normal skin flora (∼25% of cutaneous
management, 72.4% were found to be operating one abscesses caused by Staphylococcus aureus) and often
septic list per duty and 76.4% of the participants combined with organisms from adjacent mucous
following senior instructions in their practice. Only membranes [1]. Local inflammatory signs of cutaneous
46.5% inquired prior antibiotic usage for the abscess in abscesses; extreme tenderness to touch, localized swelling,
medical history, 31.5% checked for respiratory rate, erythema, temperature, the appearance of tight, shiny skin.
33.1% obtained blood culture, 74.0% did not inject Fluctuation is a reliable sign when present, although its
local anesthetics at the abscess roof , 96.1% followed absence does not rule out a deep abscess or an abscess in
incision and drainage, 22.0% followed aspiration and tissues with extensive fibrous components, such as the
antibiotics, 87.4% of the participants routinely breast, the perianal area, and fingertips. If the diagnosis is
prescribing post-operative antibiotics for every equivocal, a large gauge needle can be used to prove the

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
presence of pus within the cavity under aseptic conditions drainages such as face and genitalia as an additional
[2]
. Ultrasonography usage for confirmation of doubtful indication for antibiotic prescription [6].
cutaneous abscess is recommended especially when there
are unclear history and examination, in addition the Antibiotics that recommended by the Guidelines for
presence of lesion cellulitis [3]. Regarding to the preparation the Diagnosis and Management of Skin and Soft Tissue
of patients, Investigation is not needed for patients with Infections are Dicloxacillin, Cephalexin, Erythromycin and
uncomplicated cutaneous abscess, however patient with Amoxicillin-clavulanate, which represent different choices
symptoms and signs of Systemic Inflammatory Response of antibiotics for the cutanous abcess [5]. Johns Hopkins
Syndrome (SIRS) may needs complete blood cell (CBC) guidelines of antibiotics recommending oral trimethoprim-
count, Creatinine level Blood culture and sensitivity, C- sulfamethoxazole (co-trimoxazole) or doxycycline or
reactive protein level, Bicarbonate level and Creatine clindamycin as choices for cutaneous abscess management.
phosphokinase level. Sometime must be need to Local, Parenteral vancomycin is recommended for severe cases [6].
regional and general anesthesia are for cutaneous abscess Usage of antibiotics for abscess management without
drainage depending on abscess cavity [4]. draining will lead to a formation of Antibioma which is a
large sterile swelling, has a brownish color and needs
Incision with skin crease as far as possible is several weeks to resolve [7]. Another study on evaluate the
recommended for cutaneous abscess drainage to prevent use of systemic antibiotics, the improvement of cure rates
unsightly scars, probing in order to break the loculi and in patients with simple abscesses after incision and
drain the pus pockets is mandatory, then irrigation with drainage proving that systemic antibiotics do not
normal saline is used to wash the content of the abscess significantly improve the percentage of patients with
cavity from blood, cells debris, and pus. Packing is complete resolution of their abscesses [8].
controversy process, and dressing should be every 24 hours
until the disappearance of pus and presence of healthy Another randomized control study on assess the
granulation tissue in the cavity [4]. Some operative details of efficacy of non-packing methods in abscess drainage. The
abscess management and recommended abscess incision, results of the study showed the equal efficacy of packing
coupled with a thorough evacuation of pus and probing of and non-packing methods in terms of hemostasis and the
the cavity to break up loculation is the mainstay of therapy. prevention of reorganization of the abscess [9].
Incision management however, continues to be a wider
spectrum, with some physicians opting to cover the wound The objective is to describe the practice of surgical
with the sterile dressing, whereas others choose to pack and doctors toward cutaneous abscess management in the
close the wound, even suturing the wound at times [5]. surgical department of Khartoum and Bahri localities
teaching hospitals.
Direct Gram stain and culture of pus is recommended,
but treatment without these modalities is reasonable in II. MATERIALS AND METHODS
typical cases. The decision to administer antibiotics without
culture results (usually directed against staphylococcus  Study Design and sample size:
aureus), depends on the presence or absence of the features A descriptive Cross-sectional facility based study at
of SIRS, such as Temperature >38°C or <36°C, tachypnea the surgery emergency departments of the Khartoum and
>24 breaths per minute, tachycardia >90 beats per minute, Bahri localities teaching hospitals, there were 5 teaching
white blood cell count >12 000 or <4000 cells/µL. A hospitals in Khartoum and Bahri localities that perform
recurrent abscess is also an indication of antibiotics for 5 to emergency operations for superficial abscesses (Ibrahim
10 days after incision, drainage and obtaining of culture Malik, AL Academy, Bahri, Ali Abdalfatah, Haj Alsafy
and sensitivity. An antibiotic active against Methicillin teaching hospitals). The doctors that working in the surgical
Resistance Staphylococcus aureus (MRSA) is emergency departments of Khartoum and Bahri localities
recommended for patients with abscesses who have teaching hospitals. Pre houseman doctors, house officers,
markedly impaired host defenses or in patients with SIRS medicals, registrars, specialists, and consultants were
and hypotension [1]. included in the study, others health professional that help in
the operation like nurses and technicians were excluded.
The contrary to popular belief the addition of systemic Only cutaneous superficial abscess were included in the
antibiotics to incision and drainage of cutaneous abscesses study, perianal, breast, and organs abscesses were excluded.
does not improve cure rates even in abscesses due to
MRSA, noting that the effect of systemic antibiotics was Total coverage of all the study population in the study
oriented towards reducing recurrence rates and was area had been performed and collected through several
moderate. However, patients with immune compromise, questions asked to doctors, the independent variables were
impaired host defenses and signs of systemic infection socio-demographic characteristics of the respondents
should be given systemic antibiotics. Additional indications (Hospital name, age, gender, residency, working Status(
for the use of systemic antibiotics include multiple Number of septic lists in the duty, Cardinal history points
abscesses extremes of age, lack of response to incision and that usually inquire, Examination signs done routinely,
drainage [5]. Jon Hopkins antibiotics guidelines added the laboratory investigations requested (Random blood sugar,
association of septic phlebitis and difficult sites of complete urine general, CBC and culture and sensitivity to MRSA
screen), Confirmation of diagnosis (aspiration, Ultra

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Sound), Types of anesthesia used (Local, General, pressure, and 31.5% check the respiratory rate. Regarding
regional), type of local anesthesia ( pure local anesthetic, the investigations needed 70.1% request random blood
mixed with bicarbonate), site of local anesthesia (tissues glucose, 64.6% request a urine general test, 91% order a
around the abscess, inside the abscess or the roof of the CBC, and 33.1% of participants obtain blood cultures and,
abscess), type of Incision (with skin crease or X shape), only 3.1% request MRSA screening. Table 3
Procedure details (Probing, Irrigation Packing), type of
packing ( iodine soaked , normal saline soaked or dry About 68.5% were found to be aspirating the abscess
packing), post-operative Antibiotics, frequency of to confirm the diagnosis, 14.2% of the participants used
dressing(daily, day after day, or every two days). Ultrasound for conformation, while 28.3% of participants
don’t confirm the diagnosis. Among all participants 94.5%
 Data analysis: used local anesthesia for drainage of an abscess, 35.4%
The data were entered and proceed using Microsoft used regional anesthesia for drainage of abscesses, and
office excel version 2013. Descriptive frequency table, 54.3% opted for general anesthesia. In the population using
cross tabulation and Chi-Square test were analyzed and local anesthetics, 85% used pure local anesthesia for
interpreted using Statistical Package for Social Sciences drainage of abscess, 1.6% used Local anesthetics mixed
(SPSS) version 23 software computer package. with Bicarbonate for drainage of abscess, and 14.2% used
Local anesthetics mixed with Adrenaline, while 22.8% used
 Ethical considerations Local anesthetics with Narcotics for drainage of an abscess.
Ethical approval obtained from ethics committee in As for the route of administering their choice of local
the Graduate College, Medical and Health Studies Board – anesthetic, 94.5% of participants choose infiltration around
University of Medical Sciences & Technology, Khartoum the tissues of the abscess, 13.4% infiltrate the anesthesia
state ministry of health research department, also from inside the abscess cavity and 26% infiltrate the anesthesia
hospital's administration. Informed consent obtained from at the abscess roof. Table 4
all medical doctors voluntary participating in the study.
Regarding the indications for general anesthesia open
III. RESULTS ended question, (5.5%) of the participants were found to be
using general anesthesia for a head/neck abscess,(27.6%)
The overall response rate of the study was 60%, for a gluteal region abscess, (7.9%) in a face abscess,
Ibrahim Malik Hospital had response rate of 60%, (7.9%) if drainage via local anesthesia fails, (21.3%) in a
Academy Hospital had 33%, 76% for Bahri Hospital, 72% genital abscess, (24.4%) in deep abscess that require
for Haj Alsafy Hospital, and Ali Abdel Fatah Hospital debridement, (3.9%) in multiple abscesses, (7.9%) if it’s an
response rate was 81%. Table 1 upper limb abscess, (27.6) for a hand abscess, (3.9%) in
cases of a psychiatric patient, (15.0%) for pediatric cases,
Mean age of the participants was found to be (26.66) and (3.9%) in cases that are associated with/complicated by
years and the mean of surgical experience was (19.72) cellulitis. Among all participants, 96.1% of doctors were
months. Out of a total of 127 participants, 48% were female found to be following incision and drainage in their
and 52% were male, 44.1% of participants reside in management, 22.0% adopting aspiration and antibiotics
Khartoum, 37.8% in Bahri and 18.1% in Omdurman. method of management, 72.4% choose the method of
27.6% of participants were found to be working in Ibrahim draining the abscess by incision with the skin crease, 37.8%
Malik Hospital, 11.0% in the Academy Hospital, 33.9% in used drainage of an abscess by an X shaped incision, 67.6%
Bahri Hospital, 20.5 % in Haj Alsafy Hospital, with the perform probing, 44.1% perform irrigation, 57.5% perform
remaining 7.1% in Ali Abdelfatah Hospital. Among all packing and 18.1% of the participants applying de-roofing
participants 59.8% were found to be house officers, 7.9% in abscess drainage. Table 5
were medical officers, 26.8% were registrars, 20.4% were
specialists and only 3.1% were consultants. Only 24.4% of Among all participants 38.6% of participants use a
the participants were provided by the hospital with a normal saline soak packing after abscess drainage, 80.3%
protocol for the management of cutaneous abscesses. 10.2 of participants use iodine soak packing and 15.7% of
% of participants were following the hospital protocol in participants used dry packing. Among all participants
their practice; while 76.4% follow their senior instructions, 87.4% was prescribing antibiotics post-operatively on a
11.8% apply British guidelines and 1.6% follows routine basis. 9.4% prescribe Co-trimoxazole, 50.4%
information from textbooks. 72.4% of participants operate prescribe Amoxicillin, 6.3% prescribe Doxycycline, 35.4%
one septic list per duty, while the remaining 27.6% operate prescribe Metronidazole, 3.1% prescribe Clindamycin,
two septic lists per duty. Table 2 59.1%prescribe Augmentin, 26% prescribe Cephalosporin,
and 15% prescribe Macrolides. In the aforementioned
Among all participants 85% were found to be asking group, 59.1% of participants used separated mode of
patients about the presence of fever, 80.3% asked about a antibiotics and 52% used combination mode. Table 6
history of throbbing pain, 66.1% asked about history of
trauma in the affected area, 61.4% asked about history of Among all participants, 4.7% were found to be
recurrence, and 46.5% inquire prior usage of any antibiotic. prescribing antibiotics for immune-deficient patients, 5.5%
Among all participants 81.1% check the temperature, prescribe based on presence of signs and symptoms of
66.1% check the pulse rate, 50.4 % check the blood infection, 3.5% administer antibiotics in patients with large

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
abscess, 1.6% prescribe for patients with a high total dressing for abscess patients, (46.5%) preferred day after
WBC’s count and 3.9% due to presence of cellulitis. About day dressing and (12.6%) was performing every two days
(51.2%) of the doctors were found to be applying daily dressing. Table 6

Participants Number Total staff number Response rate


Ibrahim Malik Hospital 35 65 60%
Academy Hospital 14 42 33%
Bahri Hospital 43 56 76%
Haj Alsafy Hospital 26 36 72%
Ali Abdel Fatah Hospital 9 11 81%
Total 127 210 60%
Table 1:- Response rate of the study participants (n=127).

Mean Median Std. Deviation


Age 26.66 25 5.805
Surgical experience 19.72 3 52.56

Variable Number Percentage


Gender Female 61 48
Male 66 52

Residence Khartoum 56 44.1


Bahri 48 37.8
Omdurman 23 18.1

Ibrahim Malik Hospital 35 27.6


Academy Hospital 14 11
Hospital Name Bahri Hospital 43 33.9
Haj Alsafy Hospital 26 20.5
Ali Abdel Fatah Hospital 9 7.1

House officer 76 59.8


Medical officer 10 7.9
Current status Registrar 34 26.8
Specialist 3 2.4
Consultant 4 3.1

No Septic lists per duty One septic list per duty 92 72.4
Two septic lists per duty 35 27.6

Providing of Abscess protocol No 96 75.6


Yes 31 24.4

Senior instructions 97 76.4


Protocol of use Hospital protocol 13 10.2
British Guidelines 15 11.8
Text book information’s 2 1.6
Table 2:- Socio-demographic variable, providing and using of the cutaneous abscess protocol (n=127).

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
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Variable Number Percentage
Fever No 19 15
Yes 108 85

Throbbing pain No 25 19.7


Yes 102 80.3

Trauma history No 43 33.9


Yes 84 66.1

Recurrence No 49 38.6
Yes 78 61.4

Prior Antibiotics No 68 53.5


Yes 59 46.5

Temperature No 23 18.1
Yes 104 81.9

Pulse rate No 43 33.9


Yes 84 66.1

Blood pressure No 63 49.6


Yes 64 50.4

Respiratory Rate No 87 68.5


Yes 40 31.5

Urine General No 45 35.4


Yes 82 64.6

Random Blood Glucose No 38 29.9


Yes 89 70.1

Complete Blood Count No 11 8.7


Yes 116 91.3

Culture and Sensitivity No 85 66.9


Yes 42 33.1

MARSA Screening No 123 96.9


Yes 4 3.1
Table 3:- Demonstrate symptoms inquired in medical history and investigations examined by participants (n=127).

Variable Number Percentage


Aspiration No 40 31.5
Yes 87 68.5

Ultrasound No 109 85.8


Yes 18 14.2

Doctors do not confirm Abscess diagnosis 36 28.3

local 120 94.5


Type of anesthetics Regional 45 35.4
General 69 54.3

Doctors used pure local anesthetics No 19 15


Yes 108 85

local anesthetics mixed with bicarbonate No 125 98.4

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Yes 2 1.6

local anesthetics mixed with Adrenaline No 109 85.8


Yes 18 14.2

local anesthetics with Narcotics No 98 77.2


Yes 29 22.8

Local anesthetics Around the abscess No 7 5.5


Yes 120 94.5

Local anesthetics inside the abscess cavity No 110 86.6


Yes 17 13.4

Local anesthetics at the roof of the abscess No 94 74


Yes 33 26
Table 4:- Demonstrate the methods of diagnosis confirmation and type of anesthetic used by participants (n=127).

Variable Number Percent


Head and neck abscess 7 5.5
Gluteal region abscess 35 27.6
Face abscess 10 7.9
Failure of local anesthetics 10 7.9
Genitalia abscess 27 21.3
General anesthesia Deep abscess that needs debridement 31 24.4
Multiple abscess 5 3.9
Upper limb abscess 10 7.9
Hand abscess 35 27.6
Patients with Psychiatry illness 5 3.9
Pediatrics 19 15
Cellulitis 5 3.9

Incision and drainage No 5 3.9


Yes 122 96.1

Aspiration and antibiotics No 99 78


Yes 28 22

Incision with skin crease No 35 27.6


Yes 92 72.4

X Shape incision No 79 62.2


Yes 48 37.8

Probing No 41 32.3
Yes 86 67.7

Irrigation No 71 55.9
Yes 56 44.1

Packing No 54 42.5
Yes 73 57.5

Deroofing No 104 81.9


Yes 23 18.1
Table 5:- Indication of General anesthesia and operative techniques of abscess drainage (n=127).

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Variable Number Percentage
Dry packing No 107 84.3
Yes 20 15.7

Normal saline soaked gauze No 78 61.4


Yes 49 38.6

Iodine Soaked gauze No 25 19.7


Yes 102 80.3

Post-operative antibiotics for every abscess patient No 16 12.6


Yes 111 87.4

Co-trimixazole 12 9.4
Amoxicillin 64 50.4
Doxycycline 8 6.3
Antibiotics of choice Metronidazole 45 35.4
Clindamycin 4 3.1
Augmentin 75 59.1
Cephalosporin 33 26
Macrolides 19 15

Mode of use of Antibiotics Separated 75 59.1


In combination 52 40.9

Immunodeficient patients 6 4.7


Presence of signs and symptoms of infection 7 5.5
Indication of antibiotics Large abscess 4 3.1
High total WBCS count 2 1.6
Presence of cellulitis 5 3.9

Daily dressing No 62 48.8


Yes 65 51.2

Day after day No 68 53.5


Yes 59 46.5

Every two Days No 111 87.4


Yes 16 12.6
Table 6:- The packing of mode, antibiotic prescription and indication manners and dressing modes of the participants (n=127).

IV. DISCUSSION lead to a different approach towards the condition due to


the formation of Antibioma [7].
The study showed that with regards to physicians
approach to patients with cutaneous abscesses, major points The majority of physicians participating in the study
related to the local and systemic manifestations of thoroughly assessed patient temperature (82%), however
abscesses were thoroughly covered throughout the state, the pulse rate along with the respiratory rate were not as
with the majority of physicians enquiring about fever, enthusiastically approached, with (66%) and (68%) of
throbbing pain, history of trauma along with the history of physicians asking about the pulse and respiratory rate
recurrence of the condition. The use of antibiotics prior to respectively. Patients’ blood pressure was also a point of
hospital presentation was a point of some controversy and poor approach with almost half of the physicians (50.6%)
was not as thoroughly covered as the aforementioned choosing not to assess the patients’ blood pressure. This
points, with roughly half (46.5%) choosing to enquire about sheds light on a major issue with regards to patient care.
prior antibiotic use, whereas others chose not to. While The following physical findings have all been previously
these points can be viewed as a strong positive with regards mentioned with regards to Systemic Inflammatory
to the primary approach of physicians towards cutaneous Response Syndrome (SIRS), a point to be carefully
abscesses, prior antibiotic use for the same abscess should considered for several reasons. First and foremost SIRS is a
be routinely enquired, as their use prior to drainage may predecessor to sepsis and septic shock. It is the reaction of
the body towards systemic inflammation and an important

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
early marker for physicians, allowing simple and common improve the function of local anesthetics by neutralizing
conditions to be treated before reaching a devastating end the acidic media. Only (26%) infiltrate the anesthesia at the
result. The second point has been previously mentioned in abscess roof so the remaining doctors will cause pain for
the guidelines, as SIRS is an indication to the blind use of their patients at the time of skin incision. (94.5%) of the
antibiotics without culture results. These two factors doctors injecting local anesthetics into tissue around the
represent a point of consideration with regards to physician cavity which is beneficial for pain sedation of patients [4].
practice and patient benefit [1].
Indication of general anesthesia including large
Regarding routine investigations requested by abscess that needs debridement, local and field block is
practicing physicians, a wider spectrum of practice is recommended for the small abscess [4]. but there is many
observed with (91%) of physicians requesting a complete indications rather than large abscess for general anesthesia
blood count from their patients, (70%) of physicians in our study physicians points of view such as, Head and
routinely requesting patient random blood glucose neck abscess, Gluteal region abscess, Face abscess, Failure
measurement, and 64% ordering urine analysis. The vast of local anesthetics, Genitalia abscess, Multiple abscesses,
majority of physicians chose not to order culture and Upper limb abscess, Hand abscess, Patients with Psychiatry
sensitivity, with only (33%) of physicians stating culture illness, Pediatrics patients and association with Cellulitis
and sensitivity as a routine investigation for patients with these aspects not covered in the guidelines and no article or
cutaneous abscesses. MRSA screening via nasal swab and scientific work organizes when to choose general
skin swab, was a point of poor response with the majority anesthetics for cutaneous abscess patients.
(97%) choosing not to order this investigation as a part of
the routine management. These findings can be assessed in The vast majority of (96.1%) doctors following
several ways, partly owing to physician practice, keeping in incision and drainage method in their management which is
mind the limited facilities accessible at teaching hospitals recommended by all the guidelines [1, 6], about (22.0%)
around Khartoum. The socio economic status of patients adopting aspiration and antibiotics method of management
also plays a role in deciding what investigations are which no longer recommended. Majority of doctors
ordered, as most patients cannot afford investigations such (72.4%) applying incision with the skin crease which is
as culture and sensitivity. Investigations such as culture and recommended for prevention of unsightly scars, (37.8%)
sensitivity and MRSA screening are neither feasible nor used drainage of an abscess by an X-shaped incision, large
applicable especially in our study area which including the percentage of participants (32.3%) do not perform probing
public teaching hospitals which offering general medical which is crucial for breaking of pus flocculation and
service to the population that has high prevalence of therefore complete drainage and prevention of recurrence,
poverty. Financial considerations made in the patient’s best and its recommended by the guidelines [4, 5], (55.9%) do not
interest are also a part of the physician’s responsibility perform irrigation which results in incomplete wash out of
towards his/her patients. Doctor’s majority practice of the cavity contents in treated patients, irrigation is also
asking for routine investigations as preparation for recommended by Singhal et al [4], minority of participants
cutaneous abscess incision and drainage process, don’t (18.1%) applying de-roofing in abscess drainage and none
have any clinical weight or importance and represent of the scientific article and guidelines discussed the process
financial load either on the patients directly or in the health of the cutaneous abscess deroofing. Packing of cutaneous
insurance system for patient that has health insurance. This abscess represents a point of controversy 4 because it is
points of investigation apart from culture and sensitivity not very painful in dressing some doctors avoiding it, about
covered in the guidelines but have been discussed in half (57.5%) of the study participants applying packing.
Singhal H et al [8]. The results Leinwand Michael study showed the equal
efficacy of packing and non-packing methods in terms of
Regarding the confirmation of diagnosis majority of hemostasis and the prevention of reorganization of the
the participants (68.5%) aspirating the abscess to confirm abscess, and non-packing is superior in the aspect related to
the diagnosis, minority (14.2%) of the participants used pain reduction [9]. In general term, operative details of the
Ultrasound for conformation, while the rest of them cutaneous abscess drainage are not well covered in the
(28.3%) don’t confirm the diagnosis, confirmation of different guidelines, texts, and articles, which create a gap
diagnosis is not discussed in the guidelines but aspiration is between doctor’s practice and evidence that organize this
recommended in (Surgical Care at the District Hospital) practice.
textbook when there is doubt in the abscess diagnosis,
bedside ultrasound usage when the history and physical Regarding postoperative antibiotics prescription for
examination is not clear enough to take decision, is cutaneous abscess patients, the vast majority (87.4%) of the
recommended by Grimm [3]. study participants prescribing postoperative antibiotics
routinely for patients after incision and drainage, only
Anesthesia is the major part of the cutaneous abscess (12.6%) prescribing antibiotics when there is an indication.
incision and drainage, the vast majority (94.5%) of the A Singer and his colleague study showed antibiotics
participant used local anesthesia for drainage of an abscess, insignificant role in cutaneous abscess cure rates [8],
(35.4%) used regional anesthesia, and the (54.3%) opted for indication of antibiotics prescription is the only factor that
general anesthesia. (1.6%) used Local anesthetics mixed discussed in all cited guidelines because of its importance,
with Bicarbonate for drainage of abscess; bicarbonate can trends of the health institutes around the world running

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Volume 5, Issue 8, August – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
toward reduction of antibiotics prescription through [4]. Singhal H, RAB KK. Skin and Soft Tissue Infections
guidelines because of the antibiotics resistance that - Incision, Drainage, and Debridement Periprocedural
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operative antibiotics prescription for abscess patients periprocedure.
without indication will enlarge the danger of resistant [5]. Stevens DL, Bisno AL, Chambers HF, Everett ED,
Staphylococcus aureus, particularly methicillin-resistant Dellinger P, Goldstein EJC et al. Practice Guidelines
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[1, 6]
[6]. John Hopkins Medicines. Antibiotics Guidelines
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it is affected by the low response rate of the academy analysis. Emerg Med J. 2014. 31(7):576-578. Doi:
teaching hospital. Specialist and consultants low response 10.1136/emermed-2013-202571.
rate was also one of the limitations, some selection bias [9]. Leinwand M, Downing M, Slater D, Beck M, Burton
happened because of the 40% that did not participate in the K, Moyer D. Incision and drainage of subcutaneous
study, doctors report their practice through filing the abscesses without the use of packing. J Pediatr Surg.
surveys which created a margin of error, no others 2013 48(9):1962-1965.
limitations were found to be in the study. doi:10.1016/j.jpedsurg.2013.01.027.
[10]. Taira BR, Singer AJ, Thode HC, Lee CC. National
V. CONCLUSIONS epidemiology of cutaneous abscesses: 1996 to 2005.
Am J Emerg Med. 2009. 27(3):289-292.
Study participants showed different patterns of doi:10.1016/j.ajem.2008.02.027.
practice in cutaneous abscess management, part of this was [11]. Schaumburg F, Alabi AS, Peters G, Becker K. New
supported by the guidelines and many were not, senior epidemiology of Staphylococcus aureus infection in
instructions determined the majority practice of doctors Africa. Eur Soc Clin Infect Dis. 2014. 20:589-596.
toward cutaneous abscess management, routine prescription doi:10.1111/1469-0691.12690.
of postoperative antibiotics was one the important findings
of the study. Important aspects of cutaneous abscess
management were not covered in the guidelines including
anaesthesia, operative details, and dressing patterns.

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