Clinical Assessment

• Infected sebaceous/epidermoid cyst
• Cellulitis with or without underlying abscess
• Psoas abscess (if deep, pointing to retroperitoneum - needs USG/CT)
• Lipoma with secondary infection

Prescription

Rx

Tab. Amoxicillin + Clavulanate (Augmentin) 625 mg 1 tab twice daily (BD) after food x 7-10 days

- OR -

Tab. Cephalexin 500 mg 1 tab four times daily (QID) after food x 7-10 days

If MRSA suspected (no response in 48-72 hrs):

Tab. Co-trimoxazole (TMP 160 mg + SMX 800 mg) 1 tab twice daily (BD) x 10-14 days (Available as DS tablet - widely available in Bihar)

OR Tab. Doxycycline 100 mg 1 tab twice daily (BD) after food x 10 days

Tab. Diclofenac Sodium 50 mg + Paracetamol 325 mg 1 tab twice daily (BD) after food x 5 days

(Tab. Voveran-Plus / Combiflam - generic widely available in Bihar)

Tab. Pantoprazole 40 mg 1 tab once daily (OD) before breakfast x 5 days

Tab. Cetirizine 10 mg 1 tab at night (HS) x 5 days

Mupirocin 2% Ointment (Bactroban / T-Bact) Apply locally twice daily after cleaning the area with dilute Betadine (povidone-iodine) x 7 days

(Betadine solution 5% - dilute 1:1 with water for daily wound cleaning)

Surgical Management

• This is the primary and definitive treatment for an abscess - antibiotics alone are insufficient without I&D
• Under local anesthesia (Lignocaine 2% with adrenaline), make a linear or cruciate incision over the point of maximum fluctuance
• Drain all pus, break loculations with a finger or forceps
• Irrigate cavity with normal saline
• Pack loosely with Betadine-soaked gauze wick
• Change packing daily until cavity fills from base
• Send pus for Culture & Sensitivity (C/S) - adjust antibiotics accordingly

Investigations Advised

Dressing Protocol (Bihar Primary Care Setting)

1. Clean wound with Betadine diluted solution daily
2. Pack with Betadine-soaked ribbon gauze (wick)
3. Cover with sterile gauze pad
4. Change dressing daily or every alternate day
5. Educate patient/family on dressing technique if they are doing it at home

Lifestyle & General Advice

• Keep the area clean and dry
• Do not squeeze or press the lump
• Wear loose-fitting cotton clothing (not tight waistbands)
• Check blood sugar - recurrent boils are a red flag for undiagnosed Type 2 Diabetes Mellitus
• Avoid sharing towels, razors, or clothing (S. aureus is contagious)
• Eat high-protein diet to support healing (dal, eggs, milk, soya)
• Drink 2-3 liters water daily

Red Flags - Refer to Higher Centre / Hospital if:**

• Fever >101°F persisting after 48 hours of antibiotics
• Rapidly spreading redness (necrotizing fasciitis suspected)
• Deep/large abscess not draining properly
• Blood sugar very high (>300 mg/dL)
• Suspicion of psoas/retroperitoneal abscess on USG

Follow-up

• After 3 days - to assess response to antibiotics and dressing
• After 7 days - wound review, check C/S report, adjust antibiotics if needed
• After 14 days - final wound check and discharge/closure

Note to prescriber: In Bihar's primary care/community setting, the most practical first-line antibiotics are Amoxicillin-Clavulanate or Cephalexin (widely available, affordable, and effective against MSSA). If recurrence occurs or response is poor, switch to Co-trimoxazole DS (TMP-SMX) to cover community MRSA, which is increasingly prevalent. Always perform I&D - antibiotics alone will not resolve a formed abscess. Confirm or rule out Diabetes Mellitus as it is extremely common in Bihar and predisposes to recurrent staphylococcal infections.