5982

Randomized Clinical Trial of Packing Following Incision and Drainage of Superficial Skin Abscesses in the Pediatric Emergency Department

Friday, October 16, 2009: 5:15 PM
207A (Washington Convention Center)
David O. Kessler, MD, Michael A. Mojica, MD and Mollie Marr, Pediatrics / Emergency Medicine, New York University / Bellevue Hospital Center, NY, NY

Purpose:

Skin and soft tissue infections are on the rise in the Emergency Department (ED), accounting for as many as 6% of all visits.  However, there is surprisingly little evidence to support currently accepted practices such as wound packing. 

We hypothesize that wound packing does not affect short-term failure rates or long-term recurrences after incision and drainage (I&D) of a simple abscess.  We also hypothesize that wound packing will increase pain and visits to the ED.

Methods:

This prospective randomized trial consecutively enrolled subjects age 12 months to 25 years from an urban Pediatric ED with superficial skin/soft tissue abscesses that were deemed by a physician to need an I&D.  Patients were excluded if they were immunocompromised, had recurrence or treatment failure of a prior abscess, were spontaneously draining, required hospitalization or subspecialty management, or if the lesion was less than one centimeter, located on the face, genitalia or perianal area.  After informed consent, patients were randomized to "packing or "no packing" groups.  A standardized I&D was performed and all subjects were discharged with prescriptions for pain medicine.  Pain scores were assessed using color analogue scales before and after the procedure, and repeated at the 48hour follow-up visit.  Healing outcomes were assessed at a 48 hour follow-up visit by a blinded observer and via telephone interview at one week and one month.  Failure was defined as needing any of the following at follow-up: repeat incision and drainage, re-exploration, packing, admission, or addition or change in antibiotics. 

Results:

            These results are from a planned interim analysis for harm.  Over 6 months 50 patients were screened for eligibility, 28 were excluded, 1 was missed and 1 refused consent. The rest (n=20) were randomized and 3 were excluded from analysis due to missing data.  Groups were similar with respect to age, gender, ethnicity, abscess duration, abscess size and methicillin resistant S. Aureus rates.

Failures were more common in the packing group: 8/9 (89%) versus 2/8 (25%) in the non-packed group, p= 0.015, difference 64% (95% confidence interval 27% to 100%).  There was only one recurrence occurring in the non-packed group.  Pain and visits to the ED were not significantly different between groups. 

Conclusion:

This interim analysis of a randomized controlled trial revealed that wound packing may significantly increase the failure rates after simple I&D.  Further study is warranted to establish the reasons for this difference and test its validity.