Image-guided system endoscopic drainage of orbital abscess caused by methicillin-resistant Staphylococcus aureus in an infant

IntroductionThe management of orbital abscesses in neonates and infants is very challenging. Surgical drainage of the abscess is aimed at removing the pus and preventing blindness. We describe a case of orbital abscess in an infant that was caused by methicillin-resistant Staphylococcus aureus and that was successfully drained with image-guided endoscopic surgery.Presentation of caseA 39-day-old infant presented with progressive right maxillary swelling complicated by methicillin-resistant Staphylococcus aureus orbital abscess. Tooth bud abscess was the most likely primary cause and a combination of intravenous antibiotics was initially prescribed. The collection of intra-orbital pus was removed using image-guided system-aided endoscopic surgical drainage.DiscussionPrompt diagnosis and management are very crucial. Endoscopic drainage of these abscesses in children has been described. Image-guided drainage of the orbital abscess is a newer technique that has been reported in a teenager and in adult patients. This is the first reported case of endoscopic orbital drainage surgery in an infant. The procedure was performed successfully. This approach provides for better identification of the anatomical structures in a very young patient. Injuries to the medial rectus, globe and optic nerve can be avoided with this technique.ConclusionAggressive management of orbital abscesses in infants is mandatory. Image-guided endoscopic orbital drainage offers precise visualization and a safer technique in a relatively smaller orbit.     

Breast Abscesses: Diagnosis, Treatment and Outcome

BACKGROUND: The aim of our study was to analyze diagnostic results, different treatment modalities, and the outcome of patients with breast abscesses treated at our institution in a multi-modality breast team, to determine whether minimally invasive treatments are successful. METHODS: 110 patients with mastitis and suspected breast abscesses at our institution between January 2000 and end of September 2007 were retrospectively analyzed. Abscesses were diagnosed using ultrasonography (US), and the material obtained using US-guided fine needle aspiration (FNA) was further examined. RESULTS: 29% of the patients were treated conservatively with antibiotics only, 51% were treated with US-guided FNA or drainage placement. 11% of the patients underwent additional surgery after minimally invasive treatment (i.e. conversion rate). 9% of the patients underwent primary surgery. Early complications occurred in 7% of patients treated minimally invasive but not in patients treated with surgery alone. Late complications occurred in 5% of patients who underwent minimally invasive treatments and in 30% of patients who underwent surgery. CONCLUSIONS: US-guided FNA as a minimally invasive therapy in combination with antibiotics was found to successfully treat most breast abscesses and, in cases where a larger volume of pus was involved, the placement of an additional drainage catheter was effective.     

Management of pyogenic liver abscess in the era of computed tomography

The advent of high-resolution imaging has allowed earlier diagnosis of pyogenic liver abscess. Because radiologically guided percutaneous drainage (PCD) of liver abscesses is controversial, the authors studied 40 patients with liver abscess admitted to the Toronto Hospital between 1982 and 1987 to determine the role of PCD versus operative drainage (OD). The diagnosis of pyogenic liver abscess was made at autopsy (4 patients), at laparotomy (6) or by radiologically guided aspiration of pus (30). Ultrasonography and computed tomography were highly sensitive (85% and 96% respectively) in detecting liver abscess. Of the 36 patients treated for liver abscess all received antibiotics intravenously; 31 also underwent a drainage procedure. Treatment with antibiotics alone was associated with a success rate of 80% and a death rate of 20%. The success rate for those who had PCD was 75% with a death rate of 13%; 2 patients in this group of 16 subsequently required OD for cure. In the 15 patients initially treated with OD, success and death rates were 87% and 13% respectively. For solitary abscesses, success rates wer comparable for PCD and OD (86% and 90% respectively). For unilobar multiple abscesses the success rate was 100% for both PCD and OD, but for bilobar multiple abscesses the rates were only 40% and 67% respectively. Complication rates were similar for both methods of drainage. The authors conclude that pyogenic liver abscess can now be safely and efficaciously managed with a combination of antibiotics and PCD.     

Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success

OBJECTIVE: To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage. METHODS: In our prospective study, 30 patients with 31 breast abscesses (one patient had bilateral breast abscess) underwent percutaneous breast abscess drainage under US guidance with local anaesthesia and oral antibiotics between 1 January 2004 and 31 March 2005. These patients consisted of 16 (53.3%) non-lactating and 14 (46.7%) lactating women, with ages ranging from 18 to 68 years (median, 28 years). The racial distribution comprised 26 (86.7%) Malays, three (10%) Chinese and one (3.3%) Indian. All patients had the chief complaint of breast swelling and 25 (83.3%) had breast pain. Clinically, 28 (93.3%) were found to have a palpable mass. Nine (30%) lesions were in the upper outer quadrant of the left breast. US diameters ranged from 1 to 15 cm (median, 4 cm). The pus volumes varied from 1 to 200 mL (median, 14 mL). RESULTS: Fifteen (50%) patients required only a single aspiration, 10 required multiple aspirations and five required incision and drainage. Those patients in whom needle aspiration failed had multiloculated lesions irrespective of abscess volume and size. CONCLUSION: Needle aspiration with ultrasound guidance is an effective treatment for breast abscess irrespective of abscess volume and size.     

Rate of malignancies in breast abscesses and argument for ultrasound drainage

BACKGROUND: Biopsy of a breast abscess wall has been performed for years without evidence. Aspiration of breast abscesses has been increasing in popularity without widespread acceptance. METHODS: A 10-year retrospective review of 206 surgical biopsies after incision and drainage of breast abscesses. A literature review of breast abscess treated with ultrasound-guided aspiration. RESULTS: Over 10 years, 4.37% (9/206) patients were diagnosed with malignancy in the abscess cavity wall tissue. None of the 197 patients with a negative biopsy returned with breast cancer. Single, multiple, and combined aspiration success rates of 79.8% (364/458), 11.0% (50/458), and 90.9% (482/532) with surgical intervention necessary in 9.1% (50/532). Ultrasound versus hand guidance (92.5% versus 81.9 %, P < .01) improved success rate. CONCLUSIONS: The rate of associated malignancies with breast abscess is very low and does not warrant mandatory surgical drainage. The use of ultrasound-directed aspiration of breast abscesses is effective and should be first-line therapy.     

Management of lactational breast abscesses

The purpose of the present prospective study was to compare incision and drainage against needle aspiration for the treatment of breast abscesses in lactating women. During the 3-year study period, patients with breast abscesses were randomized 1:1 to undergo either incision and drainage (23 patients) or needle aspiration (22 patients). Ultrasound guidance was not used for any of these patients. Age, parity, localization of abscess, whether or not nipples were cracked, duration of symptoms and lactation, abscess diameter, pus culture results, breast infection history during any previous period of lactation, healing time, recurrence, cosmetic outcome in the case of incision and drainage, and volume of pus removed and number of aspirations needed in the case of aspiration were recorded. The treatment value of each of these techniques was investigated. Student's t-test, Fisher's exact test, a Chi-square test and the Mann-Whitney U-test were used for statistical analysis. In the incision and drainage group all patients were treated successfully, but 1 patient (4%) had a recurrence 2 months after complete healing and 16 patients (70%) in this group were not pleased with the cosmetic outcome. In the needle aspiration group, overall 3 patients were treated with a single aspiration and 10 patients (45%) with multiple aspirations, but 9 patients (41%) did not heal following needle aspiration and subsequently required incision and drainage in addition. No recurrences were observed in the needle aspiration group during the follow-up period. The risk factors for failure of needle aspiration for breast abscesses were abscesses larger than 5 cm in diameter, unusually large volume of aspirated pus, and delay in treatment. In conclusion, breast abscesses smaller than 5 cm in diameter on physical examination can be treated with repeated aspirations with good cosmetic results. Incision and drainage should be reserved for use in patients with larger abscesses.     

The role of percutaneous drainage of pancreatic abscesses

Pancreatic abscess remains the most lethal form of intra-abdominal abscess despite a wide variety of operative approaches that have been advocated for its control. Mortality is frequent, and recurrent abscesses after operative drainage are common. Death often results from ongoing uncontrolled sepsis. The role of percutaneous drainage (PCD) of pancreatic abscesses is controversial. Recent experience with five patients who had pancreatic abscess and in whom a combination of operative drainage and PCD proved instrumental in survival leads the authors to recommend the consideration of both forms of drainage dependent upon the circumstances. Specifically, indications for PCD may include the following: use as a temporizing measure prior to celiotomy in a critically ill patient; use in postoperative patients who have recurrent abscesses and in whom the presence of dense inflammation precludes safe evacuation of pus; and use in the patient who has known portal hypertension and in whom massive bleeding is likely to result from celiotomy and abscess drainage.     

Delayed breast abscesses after lumpectomy and radiation therapy

The incidence of delayed breast abscess as a complication following the treatment of breast cancer has not been reported. A retrospective review of 112 patients (pts) undergoing lumpectomy and radiation therapy (RT) in our institution revealed a six per cent incidence of delayed breast abscess (range 1.5-8 months, median 5 months). Prophylactic antibiotics (P = 1.0), postoperative chemotherapy (P = 1.0), primary vs. re-excisional lumpectomy (P = 1.0), and different surgeons (P = 0.514) were not associated with increased risk of delayed abscess. All abscesses occurred in the first 32 pts of this series. The size of the lumpectomy cavity correlated with the incidence of infection (P = 0.0440). Since six of seven abscess cultures grew staphylococci (coagulase negative three pts, coagulase positive three pts), and four of these pts experienced prior biopsy site infection, skin necrosis or repeated seroma aspirations, a skin source for contamination was suggested. Treatment of the abscesses with antibiotics and immediate drainage produced acceptable but inferior cosmesis. We conclude that a small but significant subset of patients treated with lumpectomy and RT will develop delayed wound infections and that expeditious treatment affords satisfactory cosmesis.     

Review of pyogenic liver abscess at the Royal Adelaide Hospital 1980-1987

Pyogenic liver abscess is an uncommon condition which carries substantial morbidity and mortality if untreated. A review was undertaken of 31 patients who were admitted to the Royal Adelaide Hospital (RAH) between January 1980 and December 1987 and who were diagnosed as having pyogenic liver abscess. The aims of the study were to review the aetiology, current methods of investigation and treatment of the disease, and to formulate a management plan based on the findings. Hypoalbuminaemia, leukocytosis and elevated alkaline phosphatase were the most common findings. Hyperbilirubinaemia was not a usual feature. Computerised tomography (CT) scanning and ultrasound were the most useful imaging modalities in identification of the abscess. The sensitivity of CT scanning in evaluating the size of abscesses was lower than anticipated and this may lead to a higher than necessary rate of surgical drainage. A case is presented to illustrate this. Most abscesses were secondary and frequently due to extension of infection from biliary structures. Diseases causing diminished resistance to bacterial infection had a significant role in the pathogenesis. The overall mortality rate was 25%. Risk factors increasing mortality included advanced age, multiplicity of abscesses, depressed immune status and the presence of complications due to the abscess. Of patients who survived, four were treated with antibiotics alone, eleven with percutaneous drainage and antibiotics, and eight with surgery and antibiotics. We conclude that patients with hepatic abscesses should be managed initially by CT or ultrasound-guided aspiration. If pus is obtained a percutaneous drain should be inserted into the cavity and systemic antibiotics administered.(ABSTRACT TRUNCATED AT 250 WORDS)     

Breast Abscesses in Lactating Women

We designed a prospective study to assess the contributing factors in puerperal breast abscess and to evaluate the treatment options. During the 4-year study period, 128 nursing women with breast infection were followed. Of these, 102 had mastitis (80%) and 26 had breast abscess (20%). Ultrasonographic examination was performed in all cases. Patient age, parity, localization of infection, cracked nipples, duration of lactation, duration of symptoms, milk culture results, breast infections during previous lactation period, treatment options, healing time, and recurrence were recorded prospectively. All mastitis patients were treated with antibiotics and none developed an abscess. Ten abscesses were aspirated, and 16 abscesses were treated by incision and drainage. Healing times were similar. There was no significant difference between mastitis and abscess groups regarding age, parity, localization of breast infection, cracked nipples, positive milk cultures, or mean lactation time. Duration of symptoms and healing were longer in cases of abscess. Multivariate analyses showed that duration of symptoms was the only independent variable for abscess development. Recurrent mastitis developed in 13 patients (10.2%) within a median of 24 weeks of follow-up. Delayed treatment of mastitis can lead to abscess formation, and it can be prevented by early antibiotic therapy. Ultrasonography is helpful for detecting abscess formation. In selected cases the abscess can be drained with needle aspiration with excellent cosmesis.     

Liver abscess: a clinicopathological analysis of 82 cases

Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.     

Study of patients with community-acquired abscesses

Abstract Background: Abscess incision and drainage (I&D) operations form the bulk of surgical procedures in the emergency department (ED). Nevertheless, epidemiologic, clinical, and bacteriology data are lacking for patients with abscesses presenting at Sudanese hospitals. Information also is unavailable on the magnitude of the problem of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and its susceptibility to the most commonly used antibiotics. Our objectives were (1) to identify and document the epidemiologic and clinical variables of patients with superficial abscesses; (2) to isolate the causative organism(s) from the pus and determine their antibiotic sensitivity; (3) to determine the prevalence of CA-MRSA and its antibiotic susceptibility; and (4) to audit our practice of I&D of abscesses. Methods: A prospective observational study, involving a convenience sample of patients who presented with community-acquired skin and soft tissue (superficial) abscesses to a single unit at Khartoum North Teaching Hospital (KNTH) ED, was done for the years 2009-2010. A pro-forma was designed to record the personal, epidemiologic, and clinical data of each patient. All I&D operations were performed as day cases. Swabs of pus drained from the abscess were sent to the laboratory for culture. Isolates underwent sensitivity testing against the most commonly used antibiotics. Results: A total of 248 patients were included. The majority (84%) were younger than 40 years of age. There were twice as many male as female patients (69% vs. 31%, respectively). The majority of patients did not have a known predisposing factor, but 13% had a history of an abscess. A history of trauma was found in 27% of the patients, whereas diabetes mellitus was found in only 6%. The most common site of the abscess was the upper limb (46%) followed by the lower limb (20%). Most (85%) of the abscesses were drained under local anesthesia. Sensitivity tests were performed on 151 pus isolates. No growth was obtained in 28 (18.5%) of the specimens. Of the 123 specimens yielding growth, S. aureus was the most common organism (90%), followed by Klebsiella spp. (6.5%). The proportion of CA-MRSA was 24%. Many of these S. aureus isolates were resistant to other antibiotics also. Conclusion: This study documents some epidemiologic and bacteriological data on one of the most common surgical problems. We found a substantial proportion of the infecting organisms to be CA-MRSA. This reflects the abuse of antibiotics in the community and stresses the importance of health education. Standardized surgical and anesthetic guidelines should be followed for I&D of abscesses to avoid recurrence. Further studies are needed urgently.     

Needle aspiration of breast abscesses

BACKGROUND: Traditional treatment of breast abscesses involves incision and drainage, with and without ultrasound guidance. These procedures cause considerable discomfort and morbidity for the patient. This study was conducted to determine whether needle aspiration of breast abscesses without ultrasound guidance was an effective treatment modality. METHOD: In our prospective study, 30 patients with 33 breast abscesses were treated by needle aspiration of pus, oral antibiotics, and repeat aspiration, if necessary. All were outpatients, and ultrasonography was not used. Twenty-five of the 30 patients were lactating. RESULTS: Eighteen patients required only a single aspiration, 9 patients required multiple aspirations, and 6 patients required incision and drainage (overall cure rate, 82%). Those patients in whom needle aspiration was successful had a significantly smaller volume of pus on initial aspiration (4.0 mL versus 21.5 mL, P = 0.002) and were more likely to have presented earlier than those not cured by aspiration (5.0 days versus 8.5 days, P = 0.006). CONCLUSION: Needle aspiration without ultrasound guidance is an effective treatment for breast abscesses.     

Streptococcus milleri in intraabdominal abscesses in children after appendectomy: incidence and course

IntroductionIntraabdominal abscesses are a common complication after appendectomy, especially in children. In this study, we describe the incidence and course of this complication in relation to the cultured pathogens found in intraabdominal abscesses.MethodsThe charts of all patients between 1 and 18 years of age undergoing appendectomy in 3 hospitals between January 2006, and July 2009, were retrospectively reviewed. Presence of an intraabdominal abscess was confirmed with abdominal ultrasound examination. We collected all details concerning the appendectomy, pus cultures, and postoperative course in these patients.ResultsTwo hundred fifty-nine patients underwent appendectomy during the study period. Subsequently, abdominal ultrasound studies showed an intraabdominal abscess in 18 (7%) patients. Intraabdominal abscesses developed more frequently after perforated appendicitis (23%) than after simple appendicitis (2%). The incidence of postoperative abscesses did not differ significantly between open (5.6%) or laparoscopic (6.3%) appendectomy. However, the rate was high (38%) in the patients in whom the appendectomy was converted from laparoscopic to open. In 15 out of the 18 patients with a postoperative abscess drainage was performed. In pus cultures of the drained abscesses Streptococcus milleri and Escherichia coli were the most commonly isolated pathogens. Presence of S milleri was associated with prolonged hospital stay (13.9 versus 9.0 days, P = .105) and prolonged antibiotic treatment (11.3 versus 4.8 days, P = .203).ConclusionsThe incidence of intraabdominal abscesses is high after perforated appendicitis in children (23%). Our data suggest that the presence of S milleri correlates with a more complicated postoperative course after appendectomy in children.     

Interventional and surgical treatment of pancreatic abscess

Pancreatic abscess is one of the infectious complications of acute pancreatitis. It is a collection principally containing pus, but it may also contain variable amounts of semisolid necrotic debris. Most of these abscesses evolve from the progressive liquefaction of necrotic pancreatic and peripancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. Included also are abscesses found after surgical débridement and drainage of pancreatic necrosis. Although open surgical treatment of infected necrosis is the established treatment of choice, percutaneous drainage of abscesses is successful in some circumstances. We used percutaneous catheter drainage in 39 patients during 1987–1995. Only 9 of 29 (31%) attempts at primary therapy were successful; 2 patients died, and 18 required subsequent surgical drainage. On the other hand, 14 of 14 patients with recurrent or residual abscesses after surgical drainage were successfully drained percutaneously. Percutaneous catheter drainage of pancreatic abscesses may be useful for initial stabilization of septic patients, drainage of further abscesses after surgical intervention (especially when access for reoperation will be difficult), associated abscesses remote from the pancreas, and selected unilocular collections at a sufficient interval after necrotizing pancreatitis to have allowed essentially complete liquefaction.     

Mycobacterium fortuitum abdominal wall abscesses following liposuction

We describe here a case of abdominal abscesses due to Mycobacterium fortuitum following liposuction. The abscesses developed three months after the procedure and diagnosis was delayed for five months. The clues for diagnosis were persistent pus discharge in spite of broad spectrum antibiotics and failure to grow any organisms on routine culture. This condition has been rarely reported; however, the increasing number of liposuction procedures done and awareness among physicians will probably result in the identification of more cases. Combination antibiotic therapy with surgical drainage in more extensive diseases is essential for cure.     

A comparison of the penetration of two quinolones into intra-abdominal abscess

A low-mortality model of an intra-abdominal abscess in the rat has been used to study the penetration of two quinolone agents into pus. Maximum concentrations in pus after intravenous injections were achieved at four hours (ciprofloxacin: 12.7 +/- 3.69 mg/L, fleroxacin: 2.25 +/- 1.82 mg/L), whereas fleroxacin given orally reached the maximum level at two hours (13.39 +/- 3.13 mg/L). Higher concentrations of fleroxacin were recorded in pus than in serum at each time point up to eight hours after administration, but pus levels of ciprofloxacin only exceeded serum levels after 1.5 hours. These antibiotics appear to have a unique property of high penetration into established abscesses and may have an important therapeutic role in the treatment of patients with multiple interloop abscesses.     

Psoas abscess rarely requires surgical intervention

BACKGROUND: Surgeons are increasingly encountering psoas abscesses. METHODS: We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm. RESULTS: Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%. CONCLUSIONS: Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.     

Spinal epidural abscess in the lumbar spine after dental extraction in a 53-year-old man

Spinal epidural abscess is rare in patients following dental extraction. Only seven cases have been described in the literature. We report the first case of an epidural abscess in the lumbar spine following dental extraction, and present a review of the relevant literature. A 53-year-old man presented with low back pain 1 week following dental extraction, and imaging revealed the presence of a lumbar epidural abscess. He underwent surgical drainage by decompressive laminectomy with evacuation of pus and debridement of the infected bone, and he was treated with a prolonged course of intravenous antibiotics. The patient demonstrated no neurologic sequelae at the 6-month follow-up examination. A search of the relevant literature showed that, of the seven epidural abscesses that occurred following dental extractions, five were cervical and two were intracranial. An epidural abscess in the lumbar spine following dental extraction had not been reported. Thus, this is the first report of an epidural abscess in the lumbar spine following dental extraction. It is also the first case of epidural abscess following dental extraction that was determined to be caused by Streptococcus suis. Our findings indicate that epidural abscess must be considered as a diagnosis for all patients presenting with intractable low back pain, with or without fever and neurologic impairment, after a recent dental extraction. We conclude that appropriate imaging must be conducted for early diagnosis.