{ "slug": "surgery-rectal", "question": "Can an anorectal abscess be treated without surgery?", "shortTitle": "Antibiotics Alone for an Anal Abscess?", "clinicalQuestion": "In adults presenting with an anorectal (perianal) abscess, does treatment with antibiotics alone, compared with surgical incision and drainage, achieve comparable rates of abscess resolution, recurrence, and subsequent fistula formation?", "pico": { "population": "Adults diagnosed with an anorectal or perianal abscess", "intervention": "Antibiotic therapy alone (non-surgical management)", "comparator": "Surgical incision and drainage", "outcomes": [ "Resolution of abscess without further intervention", "Need for subsequent surgical drainage", "Recurrence of abscess", "Development of anal fistula", "Time to symptom resolution", "Pain scores" ] }, "category": "anorectal", "relatedConditions": [ "anorectal-abscess", "perianal-abscess", "anal-fistula" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "No — for most adults, antibiotics alone are not a proven substitute for having the abscess drained.", "detail": "The one randomised trial that tested this directly in adults found the abscess came back about three times more often when treated with a needle draw-off plus antibiotics than when it was cut open and drained. Other adult studies disagree with each other, which is why this is rated low certainty rather than settled.", "studyIds": [ "pmid:33447866", "pmid:30916172" ] }, "strength": { "level": "low", "why": "One well-conducted randomised trial addresses this question directly. The studies disagree with one another, so the overall certainty is lower than any single one of them.", "override": null }, "direction": { "level": "harm-signal", "why": "A well-conducted study in people reported harm.", "override": null }, "counts": { "recordsRetrieved": 283, "recordsScreened": 197, "included": 72, "rcts": 2, "systematicReviews": 4, "observational": 23, "participants": 11312, "yearFrom": 2008, "yearTo": 2026, "registeredTrialsWithoutResults": 0 }, "excluded": [], "outcomes": [ { "name": "Resolution of the abscess without a repeat procedure", "status": "no-improvement", "note": "In the one trial that tested this directly, treating the abscess with antibiotics and a needle draw-off (instead of cutting it open) led to the abscess coming back far more often — 41% versus 15%.", "studyIds": [ "pmid:33447866" ] }, { "name": "Need for a later surgical drainage", "status": "possible-harm", "note": "People who started with antibiotics instead of a full cut-and-drain procedure were more likely to need a procedure later anyway.", "studyIds": [ "pmid:33447866" ] }, { "name": "Recurrence of the abscess", "status": "possible-harm", "note": "The randomised trial found more recurrences with antibiotics-based treatment. A small study of adults on dialysis found no clear difference between the two approaches, but it was too small and not a trial, so it can't overturn the trial's finding.", "studyIds": [ "pmid:33447866", "pmid:30916172" ] }, { "name": "Time to pain and fever going away", "status": "not-studied", "note": "No study in adults measured how fast symptoms cleared with antibiotics alone versus surgical drainage.", "studyIds": [] }, { "name": "Pain scores", "status": "not-studied", "note": "No adult study reported pain scores comparing antibiotics alone against draining the abscess.", "studyIds": [] } ], "benefits": [ { "text": "In the one trial, draining the abscess with a needle plus a week of antibiotics did work for some adults and let them skip a bigger cutting procedure — it just failed noticeably more often than standard surgery.", "studyIds": [ "pmid:33447866" ] } ], "limitations": [ { "text": "The only randomised trial on this question in adults had just 98 people — a small group for measuring something like recurrence of an infection.", "studyIds": [ "pmid:33447866" ] }, { "text": "Most other adult evidence is retrospective (looking back at medical records, not a planned trial) and comes from specific, unusual groups — people on dialysis, people with leukemia, people with Crohn's disease — whose abscesses may not behave like a typical abscess in an otherwise healthy adult.", "studyIds": [ "pmid:30916172", "pmid:23577135", "pmid:30165543" ] }, { "text": "A large share of the research on skipping surgery for an abscess was done in infants and young children, whose bodies and abscesses heal differently than adults'. Those findings cannot be assumed to carry over to grown adults.", "studyIds": [ "pmid:32785778", "pmid:21785979", "pmid:20105258", "pmid:31469939" ] } ], "risks": [ { "text": "Case reports describe adults whose abscess got worse on antibiotics alone, with spreading infection that then required urgent surgery.", "studyIds": [ "pmid:36567440", "pmid:25691848" ], "severity": "serious" }, { "text": "Choosing antibiotics instead of drainage may mean the abscess simply comes back, meaning another doctor visit and another procedure later.", "studyIds": [ "pmid:33447866" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "Fear of a cutting procedure and local anaesthesia in a sensitive area." }, { "text": "Hoping a course of pills will be simpler than scheduling a procedure." }, { "text": "Embarrassment about discussing or showing the area to a surgeon." }, { "text": "Wanting to avoid time off work or the discomfort of a wound healing open." } ], "keyStudies": [ "pmid:33447866", "pmid:30916172", "pmid:27079352", "pmid:20105258", "pmid:21785979", "pmid:32785778", "pmid:23577135" ], "studies": [ { "id": "pmid:42221001", "pmid": "42221001", "doi": "10.3389/fped.2026.1789225", "nctId": null, "pmcid": "PMC13219376", "title": "Age-stratified management of pediatric perianal abscesses: a proposed framework integrating the \"Developmental Healing Axis\"", "firstAuthor": "Yuan", "multipleAuthors": true, "journal": "Front Pediatr", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "children with perianal abscesses", "intervention": "conservative treatment with antibiotics and observation", "comparator": "surgical incision and drainage", "primaryOutcome": "healing, recurrence, and fistula formation", "result": "conservative management often works well in infants and young children, while surgery may raise fistula risk especially in older children", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a narrative review summarizing other studies and opinions rather than presenting new controlled data.", "directness": "indirect", "limitations": "The abstract does not report specific study designs, patient numbers, or statistical results; it is a conceptual synthesis rather than original research.", "followUp": "", "plainFinding": "Non-surgical care often works in young children.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42221001/", "sourceText": "Pediatric perianal abscesses represent a frequent yet underrecognized condition that poses diagnostic and therapeutic challenges due to tissue fragility and age-dependent healing dynamics. This review synthesizes current evidence on the epidemiology, pathophysiology, and management of pediatric perianal abscesses to provide a conceptual basis for clinical decision-making. Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children. In contrast, conservative strategies including antibiotic therapy and observation are often effective in infants and young children, reflecting their superior regenerative capacity. Age-related differences in immune response, microbiota composition, and glandular anatomy contribute to variations in disease progression and healing outcomes. By integrating data from recent studies and clinical guidelines, this review highlights the importance of individualized, age-specific management to optimize recovery, minimize recurrence, and prevent fistula development. Furthermore, it identifies gaps in current evidence and underscores the need for standardized treatment protocols and future research into predictive and microbiome-related factors influencing disease course.", "provenance": [ { "field": "population", "quote": "Pediatric perianal abscesses represent a frequent yet underrecognized condition" }, { "field": "intervention", "quote": "conservative strategies including antibiotic therapy and observation are often effective in infants and young children" }, { "field": "comparator", "quote": "Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children" }, { "field": "primaryOutcome", "quote": "optimize recovery, minimize recurrence, and prevent fistula development" }, { "field": "result", "quote": "conservative strategies including antibiotic therapy and observation are often effective in infants and young children, reflecting their superior regenerative capacity" } ] }, { "id": "pmid:42213056", "pmid": "42213056", "doi": "10.1097/MCG.0000000000002398", "nctId": null, "pmcid": null, "title": "Comparison of Ustekinumab and Vedolizumab Effectiveness in Perianal Crohn's Disease: A Retrospective Propensity Matched Cohort Study", "firstAuthor": "Eldesouki", "multipleAuthors": true, "journal": "J Clin Gastroenterol", "year": 2026, "design": "retrospective", "n": 1872, "nField": "reported", "population": "adults with perianal Crohn's disease", "intervention": "ustekinumab (a biologic drug)", "comparator": "vedolizumab (a biologic drug)", "primaryOutcome": "need for perianal procedures such as fistula surgery, abscess incision and drainage, diversion surgery, or antibiotics", "result": "ustekinumab had lower rates of fistula surgery and combined surgical events than vedolizumab, but incision and drainage of abscess and diversion procedure rates were not significantly different between the two drugs", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a retrospective database study comparing two drugs, not a trial testing surgery versus no surgery for abscess, so it can carry little weight on this specific question.", "directness": "indirect", "limitations": "Retrospective design using a health records database, propensity matching cannot remove all confounding, and the study compares two biologic drugs rather than directly testing whether abscess can avoid surgery.", "followUp": "1 and 2 years", "plainFinding": "No difference in abscess drainage rates", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42213056/", "sourceText": "BACKGROUND: Perianal Crohn's disease (PCD) is a severe and disabling phenotype of Crohn's disease that often requires multidisciplinary medical and surgical management. Although ustekinumab (UST) and vedolizumab (VDZ) are widely used after antitumor necrosis factor (anti-TNF) failure, direct comparative data specifically in PCD remain limited. METHODS: We conducted a multicenter, retrospective cohort study using the TriNetX US Collaborative Network to compare the effectiveness of UST versus VDZ in adults (18 y or older) with PCD between January 2017 and May 2023. Outcomes were perianal-specific clinical events, including definitive fistula surgery, incision and drainage, diversion procedures, and antibiotic use (metronidazole or ciprofloxacin), assessed at 1 and 2 years after biological initiation. Propensity score matching (PSM) (1:1) was performed to balance baseline variables. Time-to-event analyses were conducted in the matched population using Kaplan-Meier methods, and hazard ratios (HRs) were estimated using Cox proportional hazards models within the matched cohorts. RESULTS: A total of 2936 patients were identified before PSM: 1997 patients in the UST group and 939 patients in the VDZ group. After PSM, 936 patients were included in each cohort. In the matched cohorts, UST was associated with significantly lower risk of definitive perianal fistula surgery (HR: 0.66, 95% CI: 0.50-0.89; P<0.01), and composite surgical events (HR: 0.70, 95% CI: 0.54-0.87; P<0.01) compared with VDZ at 1 year. Rates of antibiotic use, incision and drainage of perianal abscess, and diversion procedures were numerically lower but not statistically significant. At 2 years, these findings persisted, with significantly lower cumulative incidence of definitive perianal fistula surgery (HR: 0.78, 95% CI: 0.61-0.90; P=0.03), composite surgical events (HR: 0.81, 95% CI: 0.69-0.90; P<0.01), and antibiotic use (HR: 0.86, 95% CI: 0.75-0.93; P=0.04) in the UST cohort compared with VDZ. Rates of incision and drainage and diversion procedures remained similar between groups. CONCLUSION: In this large real-world cohort, UST was associated with lower risks of perianal surgical interventions at one and two years and reduced antibiotic utilization at two years compared with VDZ in patients with PCD. These findings highlight meaningful differences in real-world effectiveness between therapies and support the need for prospective studies to further evaluate comparative effectiveness in this population.", "provenance": [ { "field": "population", "quote": "adults (18 y or older) with PCD" }, { "field": "intervention", "quote": "ustekinumab (UST)" }, { "field": "comparator", "quote": "vedolizumab (VDZ)" }, { "field": "primaryOutcome", "quote": "Outcomes were perianal-specific clinical events, including definitive fistula surgery, incision and drainage, diversion procedures, and antibiotic use (metronidazole or ciprofloxacin), assessed at 1 and 2 years after biological initiation." }, { "field": "result", "quote": "UST was associated with significantly lower risk of definitive perianal fistula surgery (HR: 0.66, 95% CI: 0.50-0.89; P<0.01), and composite surgical events (HR: 0.70, 95% CI: 0.54-0.87; P<0.01) compared with VDZ at 1 year. Rates of antibiotic use, incision and drainage of perianal abscess, and diversion procedures were numerically lower but not statistically significant." }, { "field": "n", "quote": "After PSM, 936 patients were included in each cohort." }, { "field": "followUp", "quote": "assessed at 1 and 2 years after biological initiation" } ] }, { "id": "pmid:42191117", "pmid": "42191117", "doi": "10.1016/j.ijmmb.2026.101156", "nctId": null, "pmcid": null, "title": "Diagnostic insight into recurrent perianal abscess caused by Cutibacterium avidum: A case report", "firstAuthor": "Sagar", "multipleAuthors": true, "journal": "Indian J Med Microbiol", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "53-year-old man with repeated perianal abscesses", "intervention": "targeted antibiotics after surgical drainage, guided by identifying the bacteria", "comparator": "previous repeated incision, drainage, and empiric antibiotics that didn't work", "primaryOutcome": "recovery without recurrence of abscess", "result": "after targeted antibiotic treatment following surgical drainage, the patient recovered fully with no further abscesses", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether avoiding surgery works in general and it actually involved surgical drainage plus antibiotics, not antibiotics alone.", "directness": "indirect", "limitations": "single case report; surgical drainage was still performed alongside targeted antibiotics, so it does not test treatment without surgery", "followUp": "", "plainFinding": "Recovered after drainage plus targeted antibiotics.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42191117/", "sourceText": "Cutibacterium avidum, a gram-positive anaerobic bacillus and skin commensal, is increasingly recognized as an opportunistic pathogen, though its association with perianal abscesses is uncommon. We describe a 53-year-old male with recurrent perianal abscesses unresponsive to repeated incision, drainage, and empiric antibiotics. Anaerobic cultures yielded small, opaque colonies identified as C. avidum by MALDI-TOF MS (VITEK® MS), confirmed on repeat isolation. Targeted therapy following surgical drainage resulted in uneventful recovery and no recurrence. This case highlights the pathogenic role of C. avidum in recurrent abscesses, emphasizing the importance of anaerobic culture and advanced identification methods in diagnosis and management.", "provenance": [ { "field": "n", "quote": "a 53-year-old male with recurrent perianal abscesses" }, { "field": "population", "quote": "a 53-year-old male with recurrent perianal abscesses unresponsive to repeated incision, drainage, and empiric antibiotics" }, { "field": "intervention", "quote": "Targeted therapy following surgical drainage resulted in uneventful recovery and no recurrence" }, { "field": "comparator", "quote": "recurrent perianal abscesses unresponsive to repeated incision, drainage, and empiric antibiotics" }, { "field": "primaryOutcome", "quote": "resulted in uneventful recovery and no recurrence" }, { "field": "result", "quote": "Targeted therapy following surgical drainage resulted in uneventful recovery and no recurrence." } ] }, { "id": "pmid:42120818", "pmid": "42120818", "doi": "10.1007/s10151-026-03319-3", "nctId": null, "pmcid": "PMC13341971", "title": "Scrotal abscesses in perianal Crohn's disease: a retrospective cohort study of clinical presentation, management, and outcomes", "firstAuthor": "Dermuth", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2026, "design": "retrospective", "n": 40, "nField": "reported", "population": "men with Crohn's disease who developed abscesses in the scrotum", "intervention": "antibiotics with or without bedside or operative drainage of the abscess", "comparator": "different drainage approaches (bedside incision and drainage versus operative drainage) within the same group", "primaryOutcome": "recurrence, need for escalation of therapy, fecal diversion, or proctectomy after treatment", "result": "All patients got antibiotics, with some having bedside drainage and others operative drainage; 40% had recurrence within a year, 20% needed treatment escalation, 35% required fecal diversion, and 20% underwent proctectomy", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a retrospective, descriptive study of a rare complication without a control group comparing surgery to no surgery, so it can't show whether avoiding surgery works.", "directness": "indirect", "limitations": "Retrospective design, no comparison group, and focuses specifically on scrotal abscesses rather than anorectal abscesses in general.", "followUp": "12 months", "plainFinding": "Describes outcomes, not surgery-avoidance.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42120818/", "sourceText": "BACKGROUND: Perianal Crohn's disease (pCD) is a severe phenotype frequently complicated by fistulas and recurrent abscesses. Although perianal sepsis is well described, genital involvement is rare, with scrotal abscesses previously reported only in case reports. Consequently, their presentation, management, and outcomes remain poorly understood. METHODS: We conducted a retrospective cohort study of male patients with Crohn's who developed scrotal abscesses between January 1, 2009, and October 31, 2024, at our quaternary referral center. Clinical records were reviewed for demographics, disease phenotype, abscess characteristics, diagnostic modality, management, microbiology, and clinical outcomes. RESULTS: A total of 40 patients were identified. Median age at abscess presentation was 42 years (IQR 34.5-50), and median BMI was 24.7 kg/m2 (IQR 22.3-31.4). Most patients had colonic disease (57.5%) and long-standing Crohn's disease. Prior Crohn's-related abscesses occurred in 82.5%, and 37.5% had a history of perianal seton placement. Abscesses were most commonly right-sided (57.5%), and 35% of patients had a scrotal fistula. Diagnosis was most frequently established using computed tomography (32.5%). All patients received antibiotics; 30% underwent bedside incision and drainage, and 37.5% underwent operative drainage. Hospital admission was required in 60%, recurrence within 12 months occurred in 40%, and escalation of advanced therapy in 20%. During follow-up, 35% required fecal diversion (72% or 25% overall), and 20% underwent proctectomy. CONCLUSION: Scrotal abscesses are an uncommon but clinically significant complication of pCD, occurring in patients with severe perianal disease and are associated with substantial morbidity. Early recognition and multidisciplinary management are essential for successful outcomes.", "provenance": [ { "field": "population", "quote": "retrospective cohort study of male patients with Crohn's who developed scrotal abscesses" }, { "field": "n", "quote": "A total of 40 patients were identified." }, { "field": "intervention", "quote": "All patients received antibiotics; 30% underwent bedside incision and drainage, and 37.5% underwent operative drainage." }, { "field": "comparator", "quote": "30% underwent bedside incision and drainage, and 37.5% underwent operative drainage" }, { "field": "primaryOutcome", "quote": "recurrence within 12 months occurred in 40%, and escalation of advanced therapy in 20%" }, { "field": "result", "quote": "Hospital admission was required in 60%, recurrence within 12 months occurred in 40%, and escalation of advanced therapy in 20%. During follow-up, 35% required fecal diversion (72% or 25% overall), and 20% underwent proctectomy." }, { "field": "followUp", "quote": "recurrence within 12 months occurred in 40%" } ] }, { "id": "pmid:42105935", "pmid": "42105935", "doi": "10.1016/j.jpeds.2026.115142", "nctId": null, "pmcid": null, "title": "Antibiotic Utilization for Perianal Fistulizing Complications among Young Patients with Crohn's Disease", "firstAuthor": "Gadepalli", "multipleAuthors": true, "journal": "J Pediatr", "year": 2026, "design": "retrospective", "n": 5277, "nField": "reported", "population": "Children and young adults with Crohn's disease, some with perianal fistulizing complications", "intervention": "Antibiotic prescriptions/dispensing patterns", "comparator": "Patients with Crohn's disease but without perianal fistulizing complications", "primaryOutcome": "Number of days of antibiotics dispensed", "result": "Patients with perianal fistulizing complications received significantly more days of antibiotics than those without, with 90% more dispensing after adjustment", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a retrospective claims-database study describing antibiotic use patterns, not a trial testing whether antibiotics can avoid surgery for abscess.", "directness": "indirect", "limitations": "Retrospective administrative claims data; studies Crohn's disease-related perianal fistulizing complications in children, not simple anorectal abscess in a general population; no data on surgical avoidance or abscess resolution outcomes.", "followUp": "", "plainFinding": "More antibiotics used, no surgery data.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42105935/", "sourceText": "OBJECTIVE: To characterize patterns of antibiotic use among children with Crohn's disease and perianal fistulizing complications (PFCs) via a large, national administrative database. STUDY DESIGN: Retrospective analysis of US administrative claims including patients ≤21 years with Crohn's disease diagnosed 2009-2018 and 5-years of continuous enrollment. We evaluated patient characteristics, medication dispensing, and disease outcomes. Multivariable negative binomial regression evaluated predictors of days of antibiotics dispensed. RESULTS: Five thousand two hundred seventy-seven patients were included, with median age 16.0 years at diagnosis (55% male, 77% commercial insurance, 61% White). In total 17% developed PFC during enrollment. Antibiotic dispensing was common, 83% had at least 1 antibiotic prescription. Patients with PFC had more antibiotic days (median 67 days, IQR 26-138) compared with those without PFC (median 27 days, IQR 10-63; P = .001). In an adjusted model, patients with PFC had 90% more antibiotic dispensing than those without PFC. CONCLUSIONS: PFCs are common and are associated with greatly increased antibiotic dispensing with 1 in 12 patients filling >20 prescriptions during the 4-year study period. The optimal use of antibiotics remains unclear, and their extensive use in this population emphasizes the need for evidence-based treatment strategies and approaches to antibiotic stewardship.", "provenance": [ { "field": "n", "quote": "Five thousand two hundred seventy-seven patients were included" }, { "field": "population", "quote": "children with Crohn's disease and perianal fistulizing complications (PFCs)" }, { "field": "intervention", "quote": "Antibiotic dispensing was common, 83% had at least 1 antibiotic prescription." }, { "field": "comparator", "quote": "Patients with PFC had more antibiotic days (median 67 days, IQR 26-138) compared with those without PFC (median 27 days, IQR 10-63; P = .001)." }, { "field": "primaryOutcome", "quote": "Multivariable negative binomial regression evaluated predictors of days of antibiotics dispensed." }, { "field": "result", "quote": "In an adjusted model, patients with PFC had 90% more antibiotic dispensing than those without PFC." } ] }, { "id": "pmid:41733318", "pmid": "41733318", "doi": "10.17992/lbl.2026.03.883", "nctId": null, "pmcid": null, "title": "[Perianal tuberculosis]", "firstAuthor": "Kristjansdottir", "multipleAuthors": true, "journal": "Laeknabladid", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "a healthy 41-year-old man diagnosed with a perianal abscess", "intervention": "surgical drainage followed by a six-month course of anti-tuberculosis medications", "comparator": "none reported (single case report)", "primaryOutcome": "healing of the perianal wound", "result": "the perianal wound healed well following anti-tuberculosis treatment after initially healing poorly post-surgery", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show whether abscesses in general can be treated without surgery.", "directness": "indirect", "limitations": "Only one patient described; the abscess was surgically drained before the underlying tuberculosis was found and treated, so it does not test avoiding surgery.", "followUp": "", "plainFinding": "TB-caused abscess healed after surgery plus TB drugs.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41733318/", "sourceText": "Perianal tuberculosis is a rare manifestation of tuberculosis. This report describes a healthy 41-year-old man diagnosed with a perianal abscess that required examination and surgical drainage under general anesthesia. The wound healed poorly over the following months, prompting repeat cultures and tissue sampling. Histological diagnosis revealed necrotizing granulomatous inflammation and acid-fast bacilli, indicating mycobacterial infection. Further investigation revealed pulmonary tuberculosis. The patient received a six-month course of anti-tuberculosis medications and recovered fully. The perianal wound healed well following treatment. Tuberculosis is an important differential diagnosis in individuals with a wound or a lesion near the anus or elsewhere that heals slowly or recurs.", "provenance": [ { "field": "n", "quote": "a healthy 41-year-old man diagnosed with a perianal abscess" }, { "field": "population", "quote": "a healthy 41-year-old man diagnosed with a perianal abscess" }, { "field": "intervention", "quote": "required examination and surgical drainage under general anesthesia" }, { "field": "intervention", "quote": "The patient received a six-month course of anti-tuberculosis medications" }, { "field": "comparator", "quote": "This report describes a healthy 41-year-old man diagnosed with a perianal abscess" }, { "field": "primaryOutcome", "quote": "The wound healed poorly over the following months" }, { "field": "result", "quote": "The perianal wound healed well following treatment" } ] }, { "id": "pmid:41579011", "pmid": "41579011", "doi": "10.1053/j.gastro.2025.08.039", "nctId": null, "pmcid": null, "title": "AGA Clinical Practice Update on Inpatient Management of Adults With Inflammatory Bowel Disease: Expert Review", "firstAuthor": "Cohen-Mekelburg", "multipleAuthors": true, "journal": "Gastroenterology", "year": 2026, "design": "guideline", "n": null, "nField": "not-reported", "population": "hospitalized adult patients with inflammatory bowel disease (IBD)", "intervention": "abscess drainage and systemic antibiotics, with medical or surgical management decided case by case", "comparator": "", "primaryOutcome": "", "result": "guideline advises that intra-abdominal abscesses in Crohn's disease be treated with drainage and antibiotics, with further medical or surgical management decided individually, but does not report whether anorectal abscess can be treated without surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is an expert consensus guideline without a systematic review of evidence or original patient data, so it cannot establish whether surgery can be avoided.", "directness": "indirect", "limitations": "Not a systematic review; based on expert opinion; focuses on intra-abdominal abscess and perianal symptoms in IBD patients generally, not specifically anorectal abscess treated without surgery.", "followUp": "", "plainFinding": "Guideline, not surgery-avoidance evidence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41579011/", "sourceText": "DESCRIPTION: Patients with inflammatory bowel disease (IBD) often require hospitalization for medically refractory IBD or IBD-related complications. However, despite the increasing availability of effective medical therapies, inpatient IBD care remains challenging, as evidenced by the variation in hospital-acquired complications, delays in surgery, and high 30-day readmission rates. Therefore, this Clinical Practice Update Expert Review is intended to provide Best Practice Advice on the evaluation and management of hospitalized adult patients with IBD. We have developed Best Practice Advice statements to address 13 key clinical issues. METHODS: This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the AGA Institute Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Prompt hospitalization should be considered for adult patients with IBD who present with severe disease refractory to outpatient treatment when there is high suspicion for an IBD-related complication, such as intestinal obstruction or intra-abdominal abscess, or when there is significant nutritional risk or failure to thrive. BEST PRACTICE ADVICE 2: The initial management of hospitalized adult patients with IBD should include supportive care. BEST PRACTICE ADVICE 3: The initial management of hospitalized adult patients with IBD should include an evaluation for IBD-related complications and concomitant infections. BEST PRACTICE ADVICE 4: Hospitalized adult patients with IBD should have their disease activity assessed with both biomarkers and endoscopic evaluation, when indicated. BEST PRACTICE ADVICE 5: Hospitalized adult patients with IBD should receive prophylactic anticoagulation for prevention of venous thromboembolism. BEST PRACTICE ADVICE 6: Hospitalized adult patients with severe ulcerative colitis should be counseled on the potential need for colectomy and should have a timely referral for surgical consultation. BEST PRACTICE ADVICE 7: Hospitalized adult patients with severe ulcerative colitis should receive initial treatment with intravenous corticosteroids at a methylprednisolone 60-mg daily dose equivalent. BEST PRACTICE ADVICE 8: Hospitalized adult patients with severe ulcerative colitis should be monitored for treatment response within 72 hours of medical treatment initiation. BEST PRACTICE ADVICE 9: Preparations should be made for initiating rescue therapy in hospitalized adult patients with severe ulcerative colitis who are not responsive to intravenous corticosteroid treatment. BEST PRACTICE ADVICE 10: In hospitalized adult patients with Crohn's disease and intestinal obstruction, medical treatment with intravenous corticosteroids should be considered when there is evidence of active inflammation. BEST PRACTICE ADVICE 11: In hospitalized adult patients with Crohn's disease and an intra-abdominal abscess, treatment should include infection control with abscess drainage (depending on size and location) and systemic antibiotics, as well as decision making regarding further medical or surgical management. BEST PRACTICE ADVICE 12: Hospitalized adult patients with Crohn's disease and active perianal symptoms should have a multidisciplinary treatment approach involving both medical and surgical care. BEST PRACTICE ADVICE 13: Stability of treatment response should be achieved before discharge, and a clear discharge transition plan established.", "provenance": [ { "field": "population", "quote": "hospitalized adult patients with IBD" }, { "field": "intervention", "quote": "treatment should include infection control with abscess drainage (depending on size and location) and systemic antibiotics, as well as decision making regarding further medical or surgical management" }, { "field": "result", "quote": "In hospitalized adult patients with Crohn's disease and an intra-abdominal abscess, treatment should include infection control with abscess drainage (depending on size and location) and systemic antibiotics, as well as decision making regarding further medical or surgical management." }, { "field": "result", "quote": "Hospitalized adult patients with Crohn's disease and active perianal symptoms should have a multidisciplinary treatment approach involving both medical and surgical care." }, { "field": "qualityWhy", "quote": "Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings of the quality of evidence or strength of the presented considerations." } ] }, { "id": "pmid:41420370", "pmid": "41420370", "doi": "10.1111/ans.70442", "nctId": null, "pmcid": null, "title": "Beyond the Knife: A Contemporary Review of Subcutaneous Abscesses", "firstAuthor": "Mersal", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with subcutaneous and perianal (anorectal) abscesses", "intervention": "post-drainage care strategies such as antibiotics, wound packing, drains, irrigation, or primary closure after incision and drainage", "comparator": "incision and drainage alone or with packing versus without packing", "primaryOutcome": "cure rates, recurrence, fistula formation, and pain after treatment", "result": "Adding antibiotics after drainage improved short-term cure and reduced new lesions for ordinary skin abscesses; for perianal abscesses, trial results conflicted though pooled data hinted at a modest benefit from antibiotics in preventing fistula; packing the wound gave no benefit and increased pain", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a narrative summary of other studies without a described systematic search or pooled statistical analysis, so its conclusions carry less certainty.", "directness": "indirect", "limitations": "The abstract does not describe its own search methodology, does not separate results clearly by abscess type for all claims, and treats incision and drainage as the assumed first step rather than testing whether surgery can be avoided.", "followUp": "", "plainFinding": "Surgery still needed; antibiotics help, packing doesn't.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41420370/", "sourceText": "Subcutaneous abscesses are among the most common soft-tissue infections encountered in acute surgical and emergency practice. While incision and drainage (I&D) remains the cornerstone of treatment, the best post-I&D strategy remains debated. Key questions include whether adjunct antibiotics improve cure rates or prevent recurrence, whether packing the cavity provides any advantage, and whether modern alternatives such as primary closure, drains, or irrigation offer superior outcomes. These issues are particularly relevant to perianal abscesses, where the risk of developing a fistula-in-ano is substantial, and to general cutaneous abscesses, where pain, delayed healing, and recurrence are frequent concerns. Recent randomized trials and contemporary guidelines have begun to clarify these controversies, helping clinicians move beyond traditional dogma toward evidence-based, patient-centered care. Landmark evidence now shows that, for uncomplicated cutaneous abscesses, adding a short course of MRSA-active antibiotics to I&D improves short-term cure and reduces new lesions. For perianal abscesses, the goal shifts to preventing fistula-in-ano: here the trials conflict, pooled estimates hint at a modest benefit from antibiotics, and clinical judgment still matters. Perhaps the clearest evidence-based shift is against routine packing, as it offers no outcome advantage and clearly increases pain. Large randomized data support abandoning it in favor of simple dressings or selective drains. Modern, patient-centered management now emphasizes thorough drainage, selective antibiotics, and avoidance of routine packing; use simple dressings or short-term drains when needed, and arrange reliable follow-up. That combination reduces pain and resource use without sacrificing safety.", "provenance": [ { "field": "population", "quote": "Subcutaneous abscesses are among the most common soft-tissue infections encountered in acute surgical and emergency practice" }, { "field": "population", "quote": "particularly relevant to perianal abscesses" }, { "field": "intervention", "quote": "whether adjunct antibiotics improve cure rates or prevent recurrence, whether packing the cavity provides any advantage, and whether modern alternatives such as primary closure, drains, or irrigation offer superior outcomes" }, { "field": "comparator", "quote": "Perhaps the clearest evidence-based shift is against routine packing" }, { "field": "primaryOutcome", "quote": "whether adjunct antibiotics improve cure rates or prevent recurrence" }, { "field": "primaryOutcome", "quote": "the risk of developing a fistula-in-ano is substantial" }, { "field": "result", "quote": "adding a short course of MRSA-active antibiotics to I&D improves short-term cure and reduces new lesions" }, { "field": "result", "quote": "the trials conflict, pooled estimates hint at a modest benefit from antibiotics" }, { "field": "result", "quote": "routine packing, as it offers no outcome advantage and clearly increases pain" } ] }, { "id": "pmid:41047078", "pmid": "41047078", "doi": "10.1016/j.clinre.2025.102706", "nctId": null, "pmcid": null, "title": "Does antibiotic therapy for anal abscess reduce the risk of fistula surgery? A retrospective study", "firstAuthor": "Alam", "multipleAuthors": true, "journal": "Clin Res Hepatol Gastroenterol", "year": 2025, "design": "retrospective", "n": 109, "nField": "reported", "population": "adults with a first-time perianal (anal) abscess treated by incision under local anesthesia", "intervention": "antibiotic therapy given after incision of the abscess", "comparator": "no antibiotic therapy after incision", "primaryOutcome": "rate of patients needing fistula surgery and/or abscess recurrence", "result": "absence of antibiotic therapy after incision was linked to higher recurrence (univariate OR 0.44 for antibiotics), but this was not confirmed in multivariate analysis due to insufficient data", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small retrospective study with only univariate analysis (no multivariate confirmation), so the antibiotic effect is uncertain.", "directness": "indirect", "limitations": "Retrospective design, no multivariate analysis possible due to insufficient data, and all patients still underwent incision rather than avoiding surgery entirely.", "followUp": "approximately 30 months", "plainFinding": "Antibiotics after drainage may lower recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41047078/", "sourceText": "BACKGROUND: Management of first-time perianal abscesses remains controversial. While the French school of proctology systematically investigates fistulas, other approaches advocate simple incision, given that over 60 % of patients do not develop recurrence. The role of post-incision antibiotic therapy is also debated. This study aimed at evaluating our department's approach to managing first perianal abscesses and identifying predictive factors for recurrence. METHODS: We retrospectively included all patients presenting in 2019 with a first perianal abscess treated by incision under local anesthesia, with or without antibiotic therapy post-incision. Patients with evident fistulas underwent surgery. Recurrence was defined as a new abscess or purulent opening. The primary outcome was the rate of patients requiring fistula surgery and/or experiencing abscess recurrence; secondary outcomes included identification of recurrence predictors. RESULTS: Among the 336 patients who consulted for an abscess, 109 were included. Among 109 patients (mean age 43 ± 13 years; 74 % male), 55 had incision alone, and 54 underwent fistula surgery. The mean follow-up for patients with incision alone was approximately 30 months, during which 18 % (10 patients) experienced abscess recurrence. Univariate logistic regression analysis revealed smoking and absence of antibiotic therapy post-incision as predictive of recurrence with (OR 0.44) were predictive of recurrence. Gender, age, BMI, diabetes, Crohn's disease, HIV infection, prior NSAID use, and abscess location were not predictive. Multivariate analysis was not conducted due to insufficient data. CONCLUSION: This study demonstrates that 41 % of patients who underwent incision for a first perianal abscess did not experience recurrence during the follow-up period. Additionally, the administration of antibiotic therapy post-incision was associated with a reduced likelihood of recurrence. However, randomized trials are warranted to validate these findings and specify the optimal antibiotic regimen.", "provenance": [ { "field": "population", "quote": "all patients presenting in 2019 with a first perianal abscess treated by incision under local anesthesia, with or without antibiotic therapy post-incision" }, { "field": "intervention", "quote": "post-incision antibiotic therapy" }, { "field": "comparator", "quote": "absence of antibiotic therapy post-incision" }, { "field": "primaryOutcome", "quote": "The primary outcome was the rate of patients requiring fistula surgery and/or experiencing abscess recurrence" }, { "field": "result", "quote": "Univariate logistic regression analysis revealed smoking and absence of antibiotic therapy post-incision as predictive of recurrence with (OR 0.44) were predictive of recurrence." }, { "field": "result", "quote": "Multivariate analysis was not conducted due to insufficient data." }, { "field": "n", "quote": "109 were included" }, { "field": "followUp", "quote": "The mean follow-up for patients with incision alone was approximately 30 months" } ] }, { "id": "pmid:40994801", "pmid": "40994801", "doi": "10.34172/mejdd.2025.417", "nctId": null, "pmcid": "PMC12456180", "title": "Comparative Approaches of Antibiotic Therapy and Surgical Intervention in Managing Recurrent Perirectal Abscess in Children Under Two Years Old", "firstAuthor": "Salimi", "multipleAuthors": true, "journal": "Middle East J Dig Dis", "year": 2025, "design": "retrospective", "n": 336, "nField": "reported", "population": "Children under two years old with perianal (perirectal) abscesses", "intervention": "Antibiotic therapy alone", "comparator": "Spontaneous drainage or surgical incision and drainage", "primaryOutcome": "Recurrence of the abscess and time to symptom resolution", "result": "Antibiotic-only group had the lowest recurrence rate and symptoms resolved in 3-10 days (average 6 days), while spontaneous drainage had a 37% recurrence rate", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective, non-randomized study where group differences (like abscess size and location) could bias the results.", "directness": "direct", "limitations": "Retrospective design without randomization; groups differed in abscess size and location, which could affect outcomes.", "followUp": "", "plainFinding": "Antibiotics alone had fewer recurrences.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40994801/", "sourceText": "BACKGROUND: Recurrent perirectal abscesses in children under 2 years pose management challenges due to high relapse risks, with limited evidence comparing long-term outcomes of antibiotic therapy versus surgical drainage. This study aimed to compare antibiotic treatment approaches and surgical interventions in managing this condition. METHODS: This retrospective cohort study analyzed 336 medical records of children under two years old with perianal abscesses treated at Hazrat Masoumeh Children's Hospital from 2012-2019. Patients were divided into three groups: antibiotic treatment only, spontaneous drainage, and incision and drainage. Data, including demographics, abscess characteristics, and treatment outcomes (recurrence, fistula formation), were analyzed using SPSS software version 26. RESULTS: A retrospective cohort study of 336 children with perianal abscesses found no significant differences in age, weight, sex, or nutritional status among the three treatment groups (P>0.05). However, statistically significant differences were observed in abscess location (distance from the anus) and size, with the incision and drainage group having larger and more distally located abscesses (P<0.05). Colic was less prevalent in the antibiotic-only group. The spontaneous drainage group had a significantly higher recurrence rate (37%). Antibiotic type distribution was similar across groups. The antibiotic-only group showed symptom resolution within 3-10 days, averaging 6 days. CONCLUSION: In general, according to the lowest rate of recurrence in the group receiving antibiotics and the average duration of short treatment of 6 days, the antibiotic approach is the preferred and primary method for the treatment and prevention of abscess recurrence.", "provenance": [ { "field": "n", "quote": "This retrospective cohort study analyzed 336 medical records of children under two years old with perianal abscesses" }, { "field": "population", "quote": "children under two years old with perianal abscesses" }, { "field": "intervention", "quote": "antibiotic treatment only" }, { "field": "comparator", "quote": "spontaneous drainage, and incision and drainage" }, { "field": "primaryOutcome", "quote": "treatment outcomes (recurrence, fistula formation)" }, { "field": "result", "quote": "The spontaneous drainage group had a significantly higher recurrence rate (37%). Antibiotic type distribution was similar across groups. The antibiotic-only group showed symptom resolution within 3-10 days, averaging 6 days." } ] }, { "id": "pmid:40983150", "pmid": "40983150", "doi": "10.1016/j.jpedsurg.2025.162691", "nctId": null, "pmcid": null, "title": "Management of Perianal Abscesses in Infants: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee", "firstAuthor": "Acker", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2025, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "infants with perianal abscess or fistula-in-ano", "intervention": "non-operative management (hygiene, sitz baths, systemic antibiotics)", "comparator": "surgical drainage (incision and drainage) or direct fistula surgery", "primaryOutcome": "failure, recurrence, and fistula formation rates after treatment", "result": "About 37.5% of non-surgical treatment failed initially, and recurrence/fistula rates were similar whether treated with non-surgical care or incision and drainage", "resultDirection": "mixed", "quality": "low", "qualityWhy": "The review is based only on lower-quality (level 3-4) studies with no randomized trials, so the comparisons are uncertain.", "directness": "indirect", "limitations": "Included only level 3-4 evidence, no randomized trials, and findings may not apply beyond the infant population studied", "followUp": "", "plainFinding": "Similar outcomes with or without surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40983150/", "sourceText": "BACKGROUND: Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA), remains controversial. There is lack of consensus regarding the risks and benefits of operative and non-operative approaches. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee created a priori consensus-based questions regarding the various approaches to management of perianal abscess and FIA in infants. A comprehensive search strategy was created, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify and review relevant articles and answer the established questions. RESULTS: Over 2460 titles and abstracts were screened to identify 31 manuscripts describing the expected course of perianal disease when managed with nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics), operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy). Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D. Recurrence after operative management of FIA, regardless of approach, is 7 %. Time to complete resolution varies widely and does not appear to differ based on treatment strategy. CONCLUSIONS: Both operative and non-operative approaches can be safely used in the management of perianal abscess and FIA but recurrence is common regardless of approach. Risks and benefits of each approach should be considered on a case-by-case basis. TYPE OF STUDY: Systematic Review of level 3-4 studies. LEVEL OF EVIDENCE: Level 4.", "provenance": [ { "field": "population", "quote": "Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA)" }, { "field": "intervention", "quote": "nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics)" }, { "field": "comparator", "quote": "operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy)" }, { "field": "primaryOutcome", "quote": "Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively." }, { "field": "result", "quote": "Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D." }, { "field": "quality", "quote": "Systematic Review of level 3-4 studies. LEVEL OF EVIDENCE: Level 4." } ] }, { "id": "pmid:40861634", "pmid": "40861634", "doi": "10.7759/cureus.88800", "nctId": null, "pmcid": "PMC12376572", "title": "Necrotizing Fasciitis Treatment With Chlorine Dioxide: A Case Report in an Immunocompromised Patient", "firstAuthor": "Callisperis", "multipleAuthors": true, "journal": "Cureus", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "a 48-year-old man with poorly controlled diabetes, liver cirrhosis, and kidney disease who developed a perianal abscess that progressed to severe tissue infection (Fournier's gangrene)", "intervention": "chlorine dioxide treatment added to standard care", "comparator": "no separate comparison group; outcome described before and after treatment", "primaryOutcome": "patient survival and recovery from severe infection", "result": "the patient survived after receiving surgical removal of infected tissue, antibiotics, chlorine dioxide, and intensive supportive care", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether treatment works in general or whether surgery can be avoided.", "directness": "indirect", "limitations": "single case, surgery was still performed alongside the experimental treatment, no comparison group, cannot isolate effect of chlorine dioxide", "followUp": "", "plainFinding": "Survived abscess, but surgery still used", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40861634/", "sourceText": "Necrotizing fasciitis is a rapidly progressive bacterial infection of the fascial planes with high morbidity and mortality, especially in immunocompromised patients. We present a case of a 48-year-old male with multiple comorbidities, including decompensated liver cirrhosis, poorly controlled diabetes mellitus, and chronic kidney disease, who developed a perianal abscess complicated by Fournier's gangrene. The case highlights the challenges in managing a complex patient with multiple organ dysfunction and demonstrates the potential therapeutic role of chlorine dioxide in treating severe soft tissue infections. Despite severe thrombocytopenia, coagulopathy, and metabolic derangements, the patient survived following surgical debridement, targeted antimicrobial therapy, innovative treatment with chlorine dioxide, and intensive supportive care. This case illustrates how prompt diagnosis, coordinated multidisciplinary care, and consideration of alternative therapeutic approaches, including chlorine dioxide, can lead to favorable outcomes even in high-risk patients with significant baseline comorbidities.", "provenance": [ { "field": "population", "quote": "a 48-year-old male with multiple comorbidities, including decompensated liver cirrhosis, poorly controlled diabetes mellitus, and chronic kidney disease, who developed a perianal abscess complicated by Fournier's gangrene" }, { "field": "intervention", "quote": "innovative treatment with chlorine dioxide" }, { "field": "comparator", "quote": "surgical debridement, targeted antimicrobial therapy, innovative treatment with chlorine dioxide, and intensive supportive care" }, { "field": "primaryOutcome", "quote": "the patient survived" }, { "field": "result", "quote": "the patient survived following surgical debridement, targeted antimicrobial therapy, innovative treatment with chlorine dioxide, and intensive supportive care" }, { "field": "n", "quote": "a 48-year-old male" } ] }, { "id": "pmid:40250758", "pmid": "40250758", "doi": "10.1016/j.gastrohep.2025.502450", "nctId": null, "pmcid": null, "title": "Spanish Working Group in Crohn's Disease and Ulcerative Colitis (GETECCU) position paper for the management of non-perianal fistulizing Crohn's disease", "firstAuthor": "Rodríguez-Lago", "multipleAuthors": true, "journal": "Gastroenterol Hepatol", "year": 2025, "design": "guideline", "n": null, "nField": "not-reported", "population": "people with Crohn's disease who develop fistulas not in the anal area", "intervention": "medical and interventional treatments (supportive care, antibiotics, biologic drugs)", "comparator": "percutaneous drainage or surgery", "primaryOutcome": "best way to manage non-perianal fistulas in Crohn's disease", "result": "the abstract does not evaluate anorectal abscess treatment; it discusses non-perianal fistulas and states that drainage or surgery remains essential in certain severe or treatment-resistant cases", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is an expert position paper about a different condition (non-perianal fistulas), not a study testing non-surgical treatment of anorectal abscess.", "directness": "indirect", "limitations": "Abstract explicitly states evidence in this area is limited and guidelines lack specific recommendations; it does not address anorectal (perianal) abscess specifically.", "followUp": "", "plainFinding": "Not directly studied here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40250758/", "sourceText": "Crohn's disease consists on a complex condition where, despite most patients initially present with an inflammatory behavior, a significant proportion develop complicated lesions such as strictures, fistulas, abscesses, or even perforations. These lesions progressively increase over time and are associated with a higher risk of surgery and hospitalization. Despite significant advances in their management after the introduction of biological therapies, particularly anti-TNF agents, these complications continue to pose challenges for the multiple professionals involved in their care. Fistulas that do not involve the perianal region (entero-enteric, entero-urinary, or entero-cutaneous) require a multidisciplinary strategy that combines medical, interventional, and surgical approaches. Their treatment ranges from general supportive measures to the use of antibiotics or, frequently, advanced therapies. Nevertheless, in cases of certain septic complications or those refractory to medical treatment, percutaneous drainage or surgical intervention remains essential. Although these lesions have a significant impact, evidence regarding the best strategies in this context, as well as the efficacy and safety of different therapies in these patients, remains limited. This is highlighted by the absence of specific recommendations in current guidelines. The objective of this document is to provide a comprehensive overview of non-perianal fistulizing Crohn's disease, addressing its epidemiological, clinical, and therapeutic aspects from a multidisciplinary perspective.", "provenance": [ { "field": "population", "quote": "Fistulas that do not involve the perianal region (entero-enteric, entero-urinary, or entero-cutaneous)" }, { "field": "intervention", "quote": "general supportive measures to the use of antibiotics or, frequently, advanced therapies" }, { "field": "comparator", "quote": "percutaneous drainage or surgical intervention remains essential" }, { "field": "primaryOutcome", "quote": "provide a comprehensive overview of non-perianal fistulizing Crohn's disease, addressing its epidemiological, clinical, and therapeutic aspects" }, { "field": "result", "quote": "in cases of certain septic complications or those refractory to medical treatment, percutaneous drainage or surgical intervention remains essential" } ] }, { "id": "pmid:40217138", "pmid": "40217138", "doi": "10.1186/s12876-025-03848-5", "nctId": null, "pmcid": "PMC11992817", "title": "Comparing surgical and conservative treatment approaches for perianal abscess in patients with hematologic malignancies: a comprehensive analysis", "firstAuthor": "Wang", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2025, "design": "retrospective", "n": 53, "nField": "reported", "population": "patients with hematologic malignancies who developed perianal abscess", "intervention": "conservative (non-surgical) drug treatment for perianal abscess", "comparator": "surgical treatment for perianal abscess", "primaryOutcome": "symptom improvement/cure and recurrence within 60 days", "result": "no significant difference in cure rates between groups; recurrence rates also not statistically different, though surgery group had numerically lower recurrence; conservative group recovered faster", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small retrospective study without randomization, so it cannot reliably separate true differences from chance or bias.", "directness": "indirect", "limitations": "Retrospective design, small sample size, specific to patients with hematologic malignancies rather than the general population.", "followUp": "60-day follow-up period", "plainFinding": "Similar healing, surgery had fewer recurrences.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40217138/", "sourceText": "Perianal abscess (PA) is a complication of infection in patients with hematologic malignancies. However, the simultaneous occurrence of neutropenia and increased susceptibility to bleeding pose significant challenges for surgical intervention in perianal abscesses. In this retrospective study, we sought to evaluate and compare the efficacy of pharmacological therapy and surgical intervention in the management of PA in patients with hematologic malignancies, bwtween 2015 and 2022 at the Fujian Medical University Union Hospital. In total, 53 patients were enrolled in this study, including 19 cases with surgical intervention, and 34 cases with conservative treatment. During the 60-day follow-up period, a significant improvement of symptoms or complete resolution was observed in 48 patients (90.5%). But the cure rates between the two groups showed no significant difference (p > 0.05). Additionally, the surgical group demonstrated a significantly lower recurrence rate compared to the conservative group, while there was no statistically significant disparity in recurrence rates (10.4% vs. 23.6%, p > 0.05). Patients with conservative treatment showed significantly shorter recovery time compared to patients with surgical treatment (p = 0.048). In conclusion, both conservative and surgical management approaches were safe and effective in relieving symptoms, but surgical intervention significantly decreased the recurrence rate. Therefore, consideration of surgical intervention is warranted for patients with recurrent perianal infections after conservative treatment.", "provenance": [ { "field": "n", "quote": "In total, 53 patients were enrolled in this study, including 19 cases with surgical intervention, and 34 cases with conservative treatment." }, { "field": "population", "quote": "Perianal abscess (PA) is a complication of infection in patients with hematologic malignancies." }, { "field": "intervention", "quote": "34 cases with conservative treatment" }, { "field": "comparator", "quote": "19 cases with surgical intervention" }, { "field": "primaryOutcome", "quote": "a significant improvement of symptoms or complete resolution was observed in 48 patients (90.5%)" }, { "field": "result", "quote": "the cure rates between the two groups showed no significant difference (p > 0.05)" }, { "field": "result", "quote": "there was no statistically significant disparity in recurrence rates (10.4% vs. 23.6%, p > 0.05)" }, { "field": "result", "quote": "Patients with conservative treatment showed significantly shorter recovery time compared to patients with surgical treatment (p = 0.048)." }, { "field": "followUp", "quote": "During the 60-day follow-up period" } ] }, { "id": "pmid:39895142", "pmid": "39895142", "doi": "10.3393/ac.2024.00472.0067", "nctId": null, "pmcid": "PMC11894937", "title": "Antibiotic use during the first episode of acute perianal sepsis: a still-open question", "firstAuthor": "Blondin", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2025, "design": "retrospective", "n": 276, "nField": "reported", "population": "patients having their first episode of acute perianal sepsis (abscess)", "intervention": "antibiotic therapy", "comparator": "no antibiotic therapy", "primaryOutcome": "development of fistula in ano at 1 year", "result": "fistula formation occurred in 54.0% of patients who received antibiotics versus 75.0% of those who did not (P<0.001), remaining significant after propensity weighting (odds ratio 0.53)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective study without randomization, so it can show a link but not prove antibiotics actually cause fewer fistulas.", "directness": "indirect", "limitations": "Retrospective design; authors state a causal relationship could not be established; no information on whether surgical drainage was performed instead of or alongside antibiotics.", "followUp": "1 year", "plainFinding": "Antibiotics linked to fewer fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39895142/", "sourceText": "PURPOSE: The role of antibiotics in preventing fistula formation following an initial abscess remains a subject of debate. This study compared the incidence of fistula in ano in patients experiencing their first episode of acute perianal sepsis, with and without antibiotic therapy, and evaluated the prevalence of fistula in ano necessitating surgical intervention at 1 year. METHODS: This retrospective cohort study was conducted at a tertiary care hospital with a dedicated proctology department. All patients who presented to the emergency proctology unit with a first episode of acute perianal sepsis were eligible for inclusion. RESULTS: This study included 276 patients. At 1 year, fistula formation was identified in 65.6% of all patients, 54.0% of those who had received antibiotics, and 75.0% of those who had not (P<0.001). This finding remained significant after weighted propensity analysis (odds ratio, 0.53; 95% confidence interval, 0.31-0.92; P=0.025). CONCLUSIONS: The rate of fistula formation was relatively high in this study. However, it was lower among patients with perianal sepsis who were treated with antibiotics, although a causal relationship could not be established. Prolonged follow-up is needed to clarify the role of antibiotic therapy in preventing or delaying fistula development in patients with acute perianal sepsis.", "provenance": [ { "field": "n", "quote": "This study included 276 patients." }, { "field": "population", "quote": "patients experiencing their first episode of acute perianal sepsis" }, { "field": "intervention", "quote": "with and without antibiotic therapy" }, { "field": "comparator", "quote": "with and without antibiotic therapy" }, { "field": "primaryOutcome", "quote": "compared the incidence of fistula in ano in patients experiencing their first episode of acute perianal sepsis" }, { "field": "result", "quote": "fistula formation was identified in 65.6% of all patients, 54.0% of those who had received antibiotics, and 75.0% of those who had not (P<0.001)" } ] }, { "id": "pmid:39784726", "pmid": "39784726", "doi": "10.17235/reed.2024.10904/2024", "nctId": null, "pmcid": null, "title": "Continuous endoscopic manual suturing for colorectal anastomotic fistula closure", "firstAuthor": "Palma García", "multipleAuthors": true, "journal": "Rev Esp Enferm Dig", "year": 2026, "design": "case-series", "n": null, "nField": "not-reported", "population": "a man with a fistula and abscess near the rectum after prior rectal cancer surgery", "intervention": "endoscopic manual suturing of the fistula opening after argon treatment", "comparator": "earlier attempts with antibiotics and vacuum-assisted closure", "primaryOutcome": "closing the fistulous opening without surgery", "result": "the opening reopened and the abscess did not fully resolve, so surgery was planned", "resultDirection": "no-benefit", "quality": "very-low", "qualityWhy": "it is a single patient case report, so it cannot show whether this approach generally works.", "directness": "indirect", "limitations": "single case, no comparison group, and the condition was a post-surgical anastomotic fistula rather than a typical anorectal abscess", "followUp": "one month of hospitalization", "plainFinding": "Nonsurgical closure failed, needed surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39784726/", "sourceText": "A 54-year-old male underwent a low anterior resection in 2015 for rectal adenocarcinoma. He presented to the emergency department with a two-week history of fever, perianal pain, an erythematous, warm, and actively draining mass. Physical examination revealed a perianal abscess in the left posterior gluteal region, with a palpable internal fistulous orifice 3 cm from the anal margin. Abdominal and pelvic CT and MRI demonstrated a discontinuity in the distal sigmoid colon pre-anastomotic, communicating with a perirectal abscess and an extrasphincteric fistulous tract towards the left ischioanal fat. Despite initial antibiotic therapy with amoxicillin/clavulanic and poor clinical response, colonoscopy revealed a 10 mm, erythematous, and friable fistulous orifice at the anastomosis. Histopathology did not reveal any adenomatous or dysplastic tissue. Vacuum-assisted closure was attempted but was unsuccessful due to technical difficulties and the small size of the cavity. Given the characteristics of the fistula, we proceeded with continuous manual suturing after argon application, achieving complete closure of the fistulous opening. However, after two weeks, there was a sluggish evolution. A follow-up colonoscopy showed persistence of the fistulous orifice with suture material, although radiologically there was a clear decrease in the abscess. Finally, after one month of hospitalization with a stable fistula but no definitive resolution, a planned surgical intervention was decided.", "provenance": [ { "field": "population", "quote": "underwent a low anterior resection in 2015 for rectal adenocarcinoma" }, { "field": "population", "quote": "perianal abscess in the left posterior gluteal region, with a palpable internal fistulous orifice 3 cm from the anal margin" }, { "field": "intervention", "quote": "we proceeded with continuous manual suturing after argon application" }, { "field": "comparator", "quote": "Vacuum-assisted closure was attempted but was unsuccessful due to technical difficulties and the small size of the cavity" }, { "field": "comparator", "quote": "Despite initial antibiotic therapy with amoxicillin/clavulanic and poor clinical response" }, { "field": "primaryOutcome", "quote": "achieving complete closure of the fistulous opening" }, { "field": "result", "quote": "A follow-up colonoscopy showed persistence of the fistulous orifice with suture material, although radiologically there was a clear decrease in the abscess" }, { "field": "result", "quote": "after one month of hospitalization with a stable fistula but no definitive resolution, a planned surgical intervention was decided" } ] }, { "id": "pmid:39734561", "pmid": "39734561", "doi": "10.7759/cureus.76456", "nctId": null, "pmcid": "PMC11681949", "title": "Intestinal Tuberculosis With Recurrent Gluteal Abscesses and Perianal Fistulas: A Case Report and Literature Review", "firstAuthor": "Takakazu Ribas Asato", "multipleAuthors": true, "journal": "Cureus", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "A 45-year-old man with chronic buttock abscess and perianal fistulas, later diagnosed with intestinal tuberculosis", "intervention": "Standard antituberculosis drugs (rifampin, isoniazid, pyrazinamide, ethambutol) plus antibiotics and antifungals, after prior surgical treatments had failed", "comparator": "No comparator; single patient followed over time with prior surgical treatments that had failed", "primaryOutcome": "Improvement of fistulas and prevention of abscess recurrence", "result": "Fistulas progressively improved with antituberculous and antimicrobial treatment after repeated surgical treatments had failed to prevent recurrence", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot reliably show whether this approach works in general.", "directness": "indirect", "limitations": "Single case report; underlying cause was intestinal tuberculosis, not a typical anorectal abscess; no control group; outcome described only as 'progressive improvement' without detailed follow-up data.", "followUp": "", "plainFinding": "Fistulas improved with TB drugs, not surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39734561/", "sourceText": "This case is relevant for describing a rare presentation of intestinal tuberculosis with perianal manifestations, complicated by abscesses and recurrent fistulas. The clinical manifestations mimicked Crohn's disease and other inflammatory conditions, making the diagnosis challenging and requiring a differentiated and meticulous diagnostic process. A 45-year-old male patient presented with a chronic abscess in the left buttock lasting for two years, characterized by spontaneous purulent drainage and multiple recurrences despite surgical and clinical treatments. Imaging findings revealed associated fistulous lesions, initially interpreted as possible inflammatory complications. The definitive diagnosis was confirmed as intestinal tuberculosis with perianal involvement through colonoscopy and biopsy, which revealed caseating granulomas. Treatment included a standard antituberculous regimen (rifampin, isoniazid, pyrazinamide, and ethambutol), along with antibiotics and antifungal agents for secondary infections. Adherence to treatment was satisfactory, with progressive improvement in the fistulas. This case highlights the importance of a comprehensive differential diagnosis in extrapulmonary tuberculosis, especially with unusual manifestations. Multidisciplinary management was essential for therapeutic success and the prevention of recurrences.", "provenance": [ { "field": "n", "quote": "A 45-year-old male patient presented with a chronic abscess in the left buttock lasting for two years" }, { "field": "population", "quote": "A 45-year-old male patient presented with a chronic abscess in the left buttock lasting for two years, characterized by spontaneous purulent drainage and multiple recurrences despite surgical and clinical treatments." }, { "field": "intervention", "quote": "Treatment included a standard antituberculous regimen (rifampin, isoniazid, pyrazinamide, and ethambutol), along with antibiotics and antifungal agents for secondary infections." }, { "field": "comparator", "quote": "multiple recurrences despite surgical and clinical treatments" }, { "field": "primaryOutcome", "quote": "Adherence to treatment was satisfactory, with progressive improvement in the fistulas." }, { "field": "result", "quote": "Adherence to treatment was satisfactory, with progressive improvement in the fistulas." } ] }, { "id": "pmid:39693822", "pmid": "39693822", "doi": "10.1016/j.jpedsurg.2024.162101", "nctId": null, "pmcid": null, "title": "Non-operative Versus Operative Management of Perianal Abscess in Infants: A 10-year Retrospective Study at Two Centres in the United Kingdom", "firstAuthor": "Neville", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2025, "design": "retrospective", "n": 116, "nField": "reported", "population": "Infants aged 12 months or younger with perianal abscess", "intervention": "Non-operative treatment (antibiotics and/or aspiration under local anaesthetic)", "comparator": "Operative treatment (incision and drainage under general anaesthesia)", "primaryOutcome": "Recurrence of perianal abscess and need for further surgery", "result": "Recurrence was significantly higher with non-operative management (53% vs 23%), and operative management was linked to lower recurrence risk; further surgery was also more common after non-operative treatment, though fistula rates were similar between groups", "resultDirection": "harm", "quality": "low", "qualityWhy": "This is a retrospective study without randomization, so differences between groups could be due to other factors rather than treatment choice.", "directness": "direct", "limitations": "Retrospective design, management based on surgeon preference, short median follow-up of 3 months", "followUp": "3 (IQR 2-6) months", "plainFinding": "Non-surgery had more recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39693822/", "sourceText": "BACKGROUND: Perianal abscess (PA), with or without fistula-in-ano (FIA) is common in infants. Treatment options include incision and drainage under general anaesthesia or non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic, which avoid the risks of surgery. Current management is based on surgeon preference due to a poor underlying evidence base. In this study we aimed to compare outcomes for non-operative and operative management of infant PA. METHODS: 10-year retrospective review (2012-2022) of infants aged ≤12 months presenting with PA to two paediatric surgery centres in the United Kingdom. Clinical features, management and outcome data were extracted from electronic records. RESULTS: 116 infants were identified; 113/116 (97 %) were male. Median age at presentation was 2 (IQR 1-6) months. Initial management was non-operative in 73/116 (63 %) and operative in 43/80 (37 %). Median follow-up was 3 (IQR 2-6) months. Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/73 [53 %] versus 10/43 [23 %], p = 0.001). Operative management was independently associated with a reduced risk of PA recurrence (OR 0.25 [95 % confidence interval 0.09-0.68], p = 0.007). Further surgery was performed in 26/73 (36 %) in the non-operative group and 7/43 (16 %) in the operative group (p = 0.026). Subsequent FIA rates were not significantly different (23/73 [32 %] versus 8/43 [19 %], p = 0.129). CONCLUSIONS: In this study, PA recurrence and the requirement for further operative intervention were significantly higher when a PA was initially managed non-operatively, although subsequent FIA rates were similar.", "provenance": [ { "field": "n", "quote": "116 infants were identified" }, { "field": "population", "quote": "infants aged ≤12 months presenting with PA" }, { "field": "intervention", "quote": "non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic" }, { "field": "comparator", "quote": "incision and drainage under general anaesthesia" }, { "field": "primaryOutcome", "quote": "Recurrence occurred in 49/116 (42 %)" }, { "field": "result", "quote": "Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/73 [53 %] versus 10/43 [23 %], p = 0.001)" }, { "field": "followUp", "quote": "Median follow-up was 3 (IQR 2-6) months" } ] }, { "id": "pmid:39004725", "pmid": "39004725", "doi": "10.1186/s12879-024-09604-6", "nctId": null, "pmcid": "PMC11246584", "title": "Butyricimonas faecihominis: an atypically resistant bacterium implicated in abscess formation - a case report", "firstAuthor": "Wessendorf", "multipleAuthors": true, "journal": "BMC Infect Dis", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "50-year-old man with perianal abscess, history of cocaine abuse and bilateral hip replacements", "intervention": "antibiotics (meropenem) plus surgery including protective transversostomy", "comparator": "", "primaryOutcome": "", "result": "Patient improved after switching to meropenem and underwent surgery, discharged after 40 days", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show whether surgery can be avoided.", "directness": "indirect", "limitations": "Single case report; patient required surgery (transversostomy) in addition to antibiotics, so it does not test non-surgical treatment alone; no comparison group.", "followUp": "six months later", "plainFinding": "Case report, surgery still needed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39004725/", "sourceText": "BACKGROUND: This case report presents a unique instance of abscesses with an uncommon pathogen isolated from blood cultures. CASE PRESENTATION: We present the case of a perianal abscess in a 50-year-old man with a history of cocaine abuse and bilateral hip replacements. The rapid progression led to septic shock and multi-organ failure, requiring intensive care unit admission, surgery including protective transversostomy. Blood cultures showed growth of Butyricimonas spp. with resistance to penicillin and piperacillin-tazobactam. The immediate switch to meropenem led to a significant improvement in the patient's condition. The patient was discharged after 40 days of hospitalization in good general condition and the reversal of the transversostomy was performed six months later. CONCLUSION: The identification of Butyricimonas faecihominis, a rarely reported pathogen, emphasizes the challenges of diagnosing and treating unusual infections. This case emphasizes the importance of rapid microbiological diagnosis, interdisciplinary collaboration, and targeted antibiotic therapy in the treatment of abscesses and sepsis.", "provenance": [ { "field": "population", "quote": "a perianal abscess in a 50-year-old man with a history of cocaine abuse and bilateral hip replacements" }, { "field": "intervention", "quote": "The immediate switch to meropenem led to a significant improvement in the patient's condition" }, { "field": "intervention", "quote": "requiring intensive care unit admission, surgery including protective transversostomy" }, { "field": "result", "quote": "The patient was discharged after 40 days of hospitalization in good general condition and the reversal of the transversostomy was performed six months later." }, { "field": "n", "quote": "We present the case of a perianal abscess in a 50-year-old man" } ] }, { "id": "pmid:37548863", "pmid": "37548863", "doi": "10.1007/s12664-023-01399-9", "nctId": null, "pmcid": null, "title": "Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn's disease: A cohort study from northern India", "firstAuthor": "Singh", "multipleAuthors": true, "journal": "Indian J Gastroenterol", "year": 2023, "design": "retrospective", "n": 27, "nField": "reported", "population": "adults with Crohn's disease who had complex perianal fistulas", "intervention": "combination medical therapy (biologics plus antibiotics/immune-suppressants) for perianal fistula, with or without surgery", "comparator": "patients who received surgery (non-cutting seton, fistulectomy, fecal diversion) in addition to medical therapy", "primaryOutcome": "clinical and MRI characteristics of complex perianal fistula, including presence of abscess and treatment received", "result": "Most patients were managed with medical therapy alone; only about one in five also had surgery, and abscess outcomes after treatment were not reported separately", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a small, descriptive cross-sectional study without a comparison group or reported outcomes for abscess treatment specifically.", "directness": "indirect", "limitations": "Single-centre, cross-sectional design with only 27 patients, all with Crohn's-related complex fistula rather than simple anorectal abscess, and no outcome data on abscess resolution with or without surgery.", "followUp": "", "plainFinding": "Mostly medical therapy, not surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37548863/", "sourceText": "BACKGROUND: Fistulizing perianal Crohn's disease (CD) is a debilitating condition associated with significant morbidity and reduction in the quality of life. Magnetic resonance imaging (MRI) of the pelvis is the preferred imaging modality for the comprehensive assessment of the perianal fistula. There is a paucity of data from India on the MRI spectrum of complex perianal fistula in CD. METHODS: A single-centre cross-sectional analysis of patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed. The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula (defined according to the American Gastroenterological Association classification) were recorded. RESULTS: Of total 175 patients with CD who attended the gastroenterology clinic during the study period, 27 (15.42%) (mean age 42±15.5 years, 62.96% females and median disease duration four years) had complex perianal fistula and were included in the analysis. The mean PDAI was 5.48±2.53. The median Van Assche Index was 17 (interquartile range [IQR] 13-19). A majority (96.29%) of the fistulae were trans-sphincteric and four (14.81%) fistulae extended into the supralevator space. All fistulae were active on MRI. Concomitant perianal abscess and proctitis were seen in 59.26% (n=16) and 62.96% (n=17) of patients, respectively. Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy. Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment. CONCLUSION: The cumulative risk of the development of fistulizing perianal CD in a northern Indian cohort was similar to the western populations. Complex perianal fistulae were predominantly trans-sphincteric and commoner in females. MRI evaluation is pivotal for the delineation of fistula anatomy, assessment of disease extent and activity and the evaluation of concomitant perianal abscess and other complications.", "provenance": [ { "field": "n", "quote": "27 (15.42%)" }, { "field": "population", "quote": "patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed" }, { "field": "intervention", "quote": "Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy." }, { "field": "comparator", "quote": "Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment." }, { "field": "primaryOutcome", "quote": "The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula" }, { "field": "result", "quote": "Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment." } ] }, { "id": "pmid:37220581", "pmid": "37220581", "doi": "10.52547/wjps.12.1.58", "nctId": null, "pmcid": "PMC10200087", "title": "Autologous Platelet-Rich Plasma Injection and Platelet-Rich Fibrin Glue Insertion for the Treatment of Extensive Supralevator Anorectal Fistula: A Case Report", "firstAuthor": "Dalili", "multipleAuthors": true, "journal": "World J Plast Surg", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "a 59-year-old man with a deep anorectal abscess and subsequent fistula", "intervention": "platelet-rich plasma injection and platelet-rich fibrin glue for fistula closure", "comparator": "none (single patient, before/after own treatment course)", "primaryOutcome": "fistula healing and symptoms like voiding problems, constipation, diarrhea, or infection", "result": "after treatment, no voiding dysfunction, constipation, diarrhea, or fistula infection at follow-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this treatment works in general.", "directness": "indirect", "limitations": "single case report; abscess was treated with surgical drainage and debridement first, and the platelet therapy was used later for the resulting fistula, not as an alternative to surgery for the abscess itself", "followUp": "11-month follow-up", "plainFinding": "Fistula healed after platelet therapy.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37220581/", "sourceText": "Supralevator fistula stays a challenge in general surgery. We present a case with supralevator anorectal fistula and subsequent retroperitoneal necrotizing fasciitis in which autologous platelet-rich plasma and platelet-rich fibrin glue were used for fistula closure. A 59-year-old man was admitted with pelvic pain and fever. Abdominopelvic sonography and CT scan reported a deep horseshoe-shaped anorectal abscess with extension to the pelvic floor, supralevator, psoas, retroperitoneal muscles, and kidneys. He was managed with antibiotics, abscess drainage, repeated radical surgical debridement, and necrosectomy. After 30 days, he was discharged, but he returned to the office with the complaint of purulent discharge from the hypogastric region and a diagnosis of fistula formation. Platelet-rich plasma was injected around the fistula into the tissue, and platelet-rich fibrin glue was introduced to the fistula tract. At the 11-month follow-up, the patient did not have voiding dysfunction, constipation, diarrhea, or fistula tract infection. Autologous platelet-rich plasma injection and platelet-rich fibrin glue insertion suggest a secure and effective approach for treating supralevator anorectal fistula.", "provenance": [ { "field": "n", "quote": "A 59-year-old man was admitted with pelvic pain and fever." }, { "field": "population", "quote": "A 59-year-old man was admitted with pelvic pain and fever." }, { "field": "intervention", "quote": "Platelet-rich plasma was injected around the fistula into the tissue, and platelet-rich fibrin glue was introduced to the fistula tract." }, { "field": "comparator", "quote": "He was managed with antibiotics, abscess drainage, repeated radical surgical debridement, and necrosectomy." }, { "field": "primaryOutcome", "quote": "At the 11-month follow-up, the patient did not have voiding dysfunction, constipation, diarrhea, or fistula tract infection." }, { "field": "result", "quote": "At the 11-month follow-up, the patient did not have voiding dysfunction, constipation, diarrhea, or fistula tract infection." } ] }, { "id": "pmid:36567440", "pmid": "36567440", "doi": "10.4166/kjg.2022.088", "nctId": null, "pmcid": "PMC12286125", "title": "Gluteal and Presacral Abscess Due to Crohn's Disease with Multiple Fistulas", "firstAuthor": "Jwa", "multipleAuthors": true, "journal": "Korean J Gastroenterol", "year": 2022, "design": "case-series", "n": 1, "nField": "reported", "population": "Young man with Crohn's disease who developed abscesses near the buttock and lower back area", "intervention": "Antibiotics alone (piperacillin/tazobactam) first, then surgical drainage", "comparator": "Antibiotics alone versus surgical drainage", "primaryOutcome": "Whether the abscess resolved and symptoms (pain, fever) went away", "result": "Antibiotics alone failed and the abscess got worse with fever; surgery to drain the abscess resolved the pain and fever", "resultDirection": "no-benefit", "quality": "very-low", "qualityWhy": "This is a single case report of an unusual, more complex abscess type (not simple perianal abscess) due to Crohn's disease, so it can't show whether typical anorectal abscess can avoid surgery.", "directness": "indirect", "limitations": "Single case, unusual abscess location tied to Crohn's disease complicated by fistulas, not a typical isolated anorectal abscess.", "followUp": "", "plainFinding": "Antibiotics alone failed, needed surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36567440/", "sourceText": "The abscess is a common complication of Crohn's disease (CD), with the perianal form more frequent than gluteal or presacral which is relatively rare. There are few case reports of gluteal abscess combined with presacral abscess caused by CD and the treatment has not been established. A 21-year-old male was admitted with right buttock and lower back pain with a duration of 3 months. He had a history of CD in the small intestine diagnosed 10 months previously. He had poor compliance and had not returned for follow-up care during the previous 6 months. Abdominopelvic CT indicated newly developed multiple abscess pockets in right gluteal region, including piriformis muscle and presacral space. Additionally, fistula tracts between small bowel loops and presacral space were observed. Patient's CD was moderate activity (273.12 on the Crohn's Disease Activity Index [CDAI]). Treatment was started with piperacillin/ tazobactam antibiotic but patient developed a fever and abscess extent was aggravated. Therefore, surgical incision and drainage was performed and 4 Penrose drains were inserted. Patient's pain and fever were resolved following surgery. Infliximab was then administered for the remaining fistulas. After the induction regimen, multiple fistula tracts improved and patient went into remission (CDAI was -0.12).", "provenance": [ { "field": "n", "quote": "A 21-year-old male was admitted with right buttock and lower back pain" }, { "field": "population", "quote": "A 21-year-old male was admitted with right buttock and lower back pain with a duration of 3 months. He had a history of CD in the small intestine diagnosed 10 months previously." }, { "field": "intervention", "quote": "Treatment was started with piperacillin/ tazobactam antibiotic but patient developed a fever and abscess extent was aggravated. Therefore, surgical incision and drainage was performed and 4 Penrose drains were inserted." }, { "field": "comparator", "quote": "Treatment was started with piperacillin/ tazobactam antibiotic but patient developed a fever and abscess extent was aggravated. Therefore, surgical incision and drainage was performed" }, { "field": "primaryOutcome", "quote": "Patient's pain and fever were resolved following surgery." }, { "field": "result", "quote": "Treatment was started with piperacillin/ tazobactam antibiotic but patient developed a fever and abscess extent was aggravated. Therefore, surgical incision and drainage was performed and 4 Penrose drains were inserted. Patient's pain and fever were resolved following surgery." } ] }, { "id": "pmid:36514644", "pmid": "36514644", "doi": "10.7759/cureus.31292", "nctId": null, "pmcid": "PMC9733662", "title": "Perianal Abscess Following Excisional Hemorrhoidectomy in an Immunocompetent Patient", "firstAuthor": "Orellana Olmedo", "multipleAuthors": true, "journal": "Cureus", "year": 2022, "design": "case-series", "n": 1, "nField": "reported", "population": "44-year-old man with no immune problems who developed a perianal abscess after hemorrhoid surgery", "intervention": "incision and drainage of the abscess plus antibiotics", "comparator": "", "primaryOutcome": "whether the abscess resolved after treatment", "result": "the patient was successfully managed with incision and drainage with antibiotics", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether avoiding surgery works in general.", "directness": "indirect", "limitations": "single case report, no comparison group, and the treatment used (incision and drainage) is itself a surgical procedure rather than a non-surgical alternative", "followUp": "", "plainFinding": "Drained abscess with antibiotics, resolved", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36514644/", "sourceText": "Hemorrhoidal disease is the third most common outpatient gastrointestinal diagnosis affecting more than four million patients annually. The management depends on the disease severity, and the treatment options range from lifestyle modification to excisional hemorrhoidectomy. Perianal abscess is an exceedingly rare complication following hemorrhoidectomy, with immunocompromised patients the most commonly affected. The rarity of this complication may be attributed to the natural immunologic process within the reticuloendothelial apparatus of the liver. The disease presentation of perianal abscess after hemorrhoidectomy and its management is unclear in the literature. We present the case of a 44-year-old immunocompetent male with grade II and III hemorrhoidal disease who underwent excisional hemorrhoidectomy that was complicated with perianal abscesses. The patient was successfully managed with incision and drainage with antibiotics. Surgeons should maintain a high index of suspicion for any sign of pelvic sepsis or a developing perianal abscess, particularly in immunocompromised patients.", "provenance": [ { "field": "n", "quote": "44-year-old immunocompetent male" }, { "field": "population", "quote": "a 44-year-old immunocompetent male with grade II and III hemorrhoidal disease who underwent excisional hemorrhoidectomy that was complicated with perianal abscesses" }, { "field": "intervention", "quote": "The patient was successfully managed with incision and drainage with antibiotics" }, { "field": "primaryOutcome", "quote": "The patient was successfully managed with incision and drainage with antibiotics" }, { "field": "result", "quote": "The patient was successfully managed with incision and drainage with antibiotics" } ] }, { "id": "pmid:34928812", "pmid": "34928812", "doi": "10.25270/wnds/091421.02", "nctId": null, "pmcid": null, "title": "Perianal Infections in Patients With Hematologic Malignancy: The Risk of Fournier's Gangrene Leading to Mortality and Irreversible Organ Damage", "firstAuthor": "Simsek", "multipleAuthors": false, "journal": "Wounds", "year": 2022, "design": "case-series", "n": 4, "nField": "reported", "population": "adults with blood cancer who developed perianal infection that progressed to Fournier's gangrene", "intervention": "antibiotics first, then surgical debridement (with diverting ostomy in most cases)", "comparator": "no comparator, single-group case series", "primaryOutcome": "death", "result": "one of four patients died despite antibiotics and surgery; one needed testicle removal", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a tiny retrospective case series of only 4 patients with a severe, different condition (gangrene, not simple abscess), so it cannot show whether surgery can be avoided.", "directness": "indirect", "limitations": "Very small sample (n=4), retrospective, no control group, and focuses on a rare complication (Fournier's gangrene) in immunocompromised cancer patients rather than typical anorectal abscess.", "followUp": "", "plainFinding": "Severe infection often needed surgery anyway.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34928812/", "sourceText": "INTRODUCTION: The efficacy of surgical intervention for perianal infection in patients with hematologic malignancy is not well-established. OBJECTIVE: This article presents a case series of perianal infection progressing to Fournier's gangrene (FG) in patients with hematologic malignancy to guide physicians, because to the author's knowledge, there were no randomized or prospective studies presenting the management strategies reported herein. It was hypothesized that surgery might reduce mortality and morbidity in patients with inflammation spreading beyond the perianal region, in patients with abscess formation, and in those who show no improvement with medical therapy. MATERIALS AND METHODS: The data of 4 adults with hematologic malignancy who developed perianal infection progressing to FG between January 2010 and December 2018 were reviewed retrospectively. Patients younger than 18 years and patients without hematologic malignancies or FG were excluded. The primary outcome was mortality. The secondary outcome was irreversible organ damage. RESULTS: Four male patients with a mean age of 36.75 years ± 13.1 standard deviation (range, 23-52 years) reported fever and dull anal pain during treatment for hematologic malignancy. A broad-spectrum antibiotic regimen was administered as initial empiric therapy at onset of fever and was de-escalated based on the culture results and clinical response. However, FG arose in all cases approximately 8.75 days ± 6.94 (range, 3-17 days) after onset of anal pain. All patients underwent surgical debridement, and diverting ostomy was performed in 3 cases. One patient died of overwhelming sepsis (25%), and 1 patient required orchiectomy (25%). CONCLUSIONS: Clinical suspicion of FG may be effective in reducing mortality in patients with hematologic malignancy, especially in cases with fever accompanied by anal pain. Surgical intervention may improve the prognosis for patients with inflammation spreading beyond the perianal region, patients with abscess formation, those who show no improvement in medical therapy, and those who develop FG. Diverting ostomy may improve survival in patients with FG.", "provenance": [ { "field": "population", "quote": "4 adults with hematologic malignancy who developed perianal infection progressing to FG" }, { "field": "intervention", "quote": "A broad-spectrum antibiotic regimen was administered as initial empiric therapy at onset of fever and was de-escalated based on the culture results and clinical response." }, { "field": "intervention", "quote": "All patients underwent surgical debridement, and diverting ostomy was performed in 3 cases." }, { "field": "comparator", "quote": "The data of 4 adults with hematologic malignancy who developed perianal infection progressing to FG between January 2010 and December 2018 were reviewed retrospectively." }, { "field": "primaryOutcome", "quote": "The primary outcome was mortality." }, { "field": "result", "quote": "One patient died of overwhelming sepsis (25%), and 1 patient required orchiectomy (25%)." }, { "field": "n", "quote": "Four male patients with a mean age of 36.75 years" } ] }, { "id": "pmid:34731938", "pmid": "34731938", "doi": "10.3393/ac.2021.00332.0047", "nctId": null, "pmcid": "PMC8566151", "title": "Perianal Actinomycosis: A Surgeon's Perspective and Review of Literature", "firstAuthor": "Dosis", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2021, "design": "retrospective", "n": 5, "nField": "reported", "population": "patients with perianal actinomycosis infection (a rare bacterial cause of anorectal disease)", "intervention": "prolonged antibiotic therapy plus surgery", "comparator": "no comparator group; description of treatment used in these cases", "primaryOutcome": "whether infection was eradicated with treatment", "result": "all identified perianal actinomycosis cases required both prolonged antibiotics and surgical treatment", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a tiny retrospective case series (5 relevant patients) of a rare specific infection, not a controlled study of typical anorectal abscess.", "directness": "indirect", "limitations": "Retrospective design, very small number of perianal cases, no control group, and findings specific to a rare bacterial cause (Actinomyces) rather than typical anorectal abscess.", "followUp": "", "plainFinding": "Needed both antibiotics and surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34731938/", "sourceText": "Actinomycosis is a serious suppurative, bacterial infection caused by the gram-positive anaerobic Actinomyces species. Primary perianal actinomycosis is rare and challenging for the colorectal surgeon. We aimed to present our experience and compare this with available literature. All patients with isolated Actinomyces on microbiology reports, between January 2013 and February 2021, were identified and reviewed. Data collection was retrospective based on electronic patient records. The site of infection and treatment strategy were examined. Perianal cases were evaluated in depth. All publications available in the literature were interrogated. Fifty-nine cases of positive actinomycosis cultures were reviewed. Six cases of colonization were excluded. Actinomyces turicensis was the most common organism isolated. Five cases of perianal actinomycosis were identified requiring prolonged antibiotic and surgical therapy. Twenty-one studies, most case reports, published since 1951 were also reviewed. Diagnosis of perianal actinomycosis may be challenging but should be suspected particularly in recurrent cases. Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium. An extended course of antibiotic therapy (months) is required for eradication in certain cases.", "provenance": [ { "field": "population", "quote": "Primary perianal actinomycosis is rare and challenging for the colorectal surgeon." }, { "field": "n", "quote": "Five cases of perianal actinomycosis were identified requiring prolonged antibiotic and surgical therapy." }, { "field": "intervention", "quote": "requiring prolonged antibiotic and surgical therapy" }, { "field": "comparator", "quote": "The site of infection and treatment strategy were examined." }, { "field": "primaryOutcome", "quote": "An extended course of antibiotic therapy (months) is required for eradication in certain cases." }, { "field": "result", "quote": "Five cases of perianal actinomycosis were identified requiring prolonged antibiotic and surgical therapy." } ] }, { "id": "pmid:34645489", "pmid": "34645489", "doi": "10.1186/s13099-021-00457-x", "nctId": null, "pmcid": "PMC8511849", "title": "Coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess diagnosed by 16S rDNA sequencing: a case report", "firstAuthor": "Sun", "multipleAuthors": true, "journal": "Gut Pathog", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "a 53-year-old patient with a gas-producing perianal abscess", "intervention": "antibiotics (ceftizoxime and ornidazole, later meropenem and vancomycin) plus debridement and drainage surgery", "comparator": "none reported", "primaryOutcome": "resolution of infection and successful identification of causative bacteria", "result": "the patient required two surgical debridements along with antibiotics before recovering and being discharged", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether avoiding surgery works in general.", "directness": "indirect", "limitations": "single case, no comparison group, and the abscess was a rare gas-producing clostridial/coli coinfection rather than a typical anorectal abscess.", "followUp": "27 days of admission", "plainFinding": "Needed surgery despite antibiotics.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34645489/", "sourceText": "BACKGROUND: Gas-producing perianal abscess raises the possibility of clostridial infection, with Clostridium perfringens being the most common causative agent, which is highly lethal if untreated timely. As the treatment of clostridial infections often differs from that of non-clostridial infections, which they may closely resemble, the importance of accurate pathogenic organism identification cannot be overemphasized. The 16S rDNA of bacteria is highly conserved within a species and among species of the same genus but demonstrates substantial variation between different species, thus making it a suitable genomic candidate for bacterial detection and identification. CASE PRESENTATION: Here, we report the case of a 53-year-old patient who was admitted to the hospital for a gas-producing perianal abscess. The patient was managed with ceftizoxime and ornidazole and then received debridement and drainage at the lesion on the second day after admission. The bacterial cultures of the patient isolates from the debridement showed a coinfection of Escherichia coli and Enterococcus faecium. Although perianal redness and swelling subsided obviously after the surgery, the patient was febrile to 38.3℃ with his left upper thigh red and swollen, aggravated with tenderness and crepitus. Considering insufficient debridement and the risk of incorrect identification of pathogens, a second debridement and drainage were performed 4 days after the primary operation, and 16S rDNA sequencing of the isolates implicated Clostridium perfringens infection. Given the discrepancies in diagnostic results and the treatment outcomes, Enterococcus faecium was identified as sample contamination, and a diagnosis of coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess was confirmed. The patient was then successfully treated with meropenem and vancomycin and was discharged at 27 days of admission. CONCLUSIONS: This case represents the first report of coinfection of both clostridial and non-clostridial organisms in gas-producing perianal abscess and the first case reporting the use of 16S rDNA sequencing in the diagnosis of perianal abscess. Timely pathogen identification is critical for treating gas-producing perianal abscess and an antibiotic regimen covering both aerobic and anaerobic organisms is recommended before true pathogens are identified.", "provenance": [ { "field": "population", "quote": "a 53-year-old patient who was admitted to the hospital for a gas-producing perianal abscess" }, { "field": "intervention", "quote": "The patient was managed with ceftizoxime and ornidazole and then received debridement and drainage at the lesion on the second day after admission" }, { "field": "intervention", "quote": "The patient was then successfully treated with meropenem and vancomycin" }, { "field": "comparator", "quote": "CASE PRESENTATION" }, { "field": "primaryOutcome", "quote": "Timely pathogen identification is critical for treating gas-producing perianal abscess" }, { "field": "result", "quote": "a second debridement and drainage were performed 4 days after the primary operation" }, { "field": "result", "quote": "was discharged at 27 days of admission" }, { "field": "n", "quote": "a 53-year-old patient" }, { "field": "followUp", "quote": "was discharged at 27 days of admission" } ] }, { "id": "pmid:34616267", "pmid": "34616267", "doi": "10.1159/000515611", "nctId": null, "pmcid": "PMC8454242", "title": "Multidrug Resistance and Flaring up of Manifestation in Fistulizing Crohn's Disease after Surgery on a Perianal Lesion", "firstAuthor": "Ali", "multipleAuthors": true, "journal": "Case Rep Gastroenterol", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "48-year-old woman with Crohn's disease and a perianal abscess", "intervention": "surgical incision and drainage of the abscess", "comparator": "none reported", "primaryOutcome": "wound healing and infection after surgery", "result": "developed delayed wound healing with highly drug-resistant bacterial infection after abscess surgery", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show whether surgery or non-surgical treatment is better for most people.", "directness": "indirect", "limitations": "Single case report with no comparison group, so findings may not apply broadly; the abstract itself calls for surgery rather than testing an alternative.", "followUp": "", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34616267/", "sourceText": "Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract with relapsing and remitting episodes. Abscesses and fistulas are the most common presentations of anorectal Crohn's disease. Antibiotics and surgical incision and drainage have been successful in treating perianal disease. We present here a 48-year-old woman with known case of Crohn's disease who presented with massive swelling in the perianal region with severe throbbing pain and high-grade fever, 38.2°C; the surgeon noted a large perianal abscess near the anal verge with redness, hotness, and tenderness. One and a half months from perianal abscess surgery, culture sensitivity was done due to delayed wound healing and passage of greenish discharge, and it revealed highly resistant bacteria Proteus mirabilis, Escherichia coli, and Staphylococci. In conclusion, clinicians should be aware that abscess and fistula have a fair chance to develop in Crohn's disease patients who are using immunomodulating and immunosuppressant therapy. In abscess and fistula cases, surgery should be determined as soon as possible, and close clinical monitoring should be performed. We recommend routine screening for enteric fistula and culture sensitivity of any discharge prior to the initiation of any antibiotic. Appropriate intervention should then be undertaken.", "provenance": [ { "field": "n", "quote": "a 48-year-old woman" }, { "field": "population", "quote": "48-year-old woman with known case of Crohn's disease who presented with massive swelling in the perianal region" }, { "field": "intervention", "quote": "surgical incision and drainage" }, { "field": "comparator", "quote": "Antibiotics and surgical incision and drainage have been successful in treating perianal disease." }, { "field": "primaryOutcome", "quote": "culture sensitivity was done due to delayed wound healing and passage of greenish discharge" }, { "field": "result", "quote": "it revealed highly resistant bacteria Proteus mirabilis, Escherichia coli, and Staphylococci" } ] }, { "id": "pmid:34239275", "pmid": "34239275", "doi": "10.3748/wjg.v27.i24.3643", "nctId": null, "pmcid": "PMC8240051", "title": "Stem cell injection for complex anal fistula in Crohn's disease: A single-center experience", "firstAuthor": "Schwandner", "multipleAuthors": false, "journal": "World J Gastroenterol", "year": 2021, "design": "retrospective", "n": 12, "nField": "reported", "population": "adults with complex anal fistula caused by Crohn's disease, without active disease or abscess", "intervention": "local injection of stem cells (darvadstrocel) into the fistula after seton removal and surgical preparation", "comparator": "none - single group before/after comparison", "primaryOutcome": "fistula healing rate", "result": "66.7% (8 of 12) of fistulas healed, but 33.3% of patients later needed surgery again for a new perianal abscess", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "Only 12 patients were studied without a comparison group, and the data were looked at after the fact, so the results could easily be due to chance or selection.", "directness": "indirect", "limitations": "small number of patients, retrospective analysis, no control group, and patients with abscess were excluded from treatment", "followUp": "mean 14.3 (range: 3-30) mo", "plainFinding": "Fistula healed in two-thirds; abscess still occurred in some.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34239275/", "sourceText": "BACKGROUND: Despite tremendous progress in medical therapy and optimization of surgical strategies, considerable failure rates after surgery for complex anal fistula in Crohn's disease have been reported. Therefore, stem cell therapy for the treatment of complex perianal fistula can be an innovative option with potential long-term healing. AIM: To evaluate the results of local administration of allogenic, adipose-derived mesenchymal stem cells (darvadstrocel) for complex anal Crohn's fistula. METHODS: All patients with complex anal fistulas associated with Crohn's disease who were amenable for definite fistula closure within a defined observation period were potential candidates for stem cell injection (darvadstrocel) if at least one conventional or surgical attempt to close the fistula had failed. Darvadstrocel was only indicated in patients without active Crohn's disease and without presence of anorectal abscess. Local injection of darvadstrocel was performed as a standardized procedure under general anesthesia including single-shot antibiotic prophylaxis, removal of seton drainage, fistula curettage, closure of the internal openings and local stem cell injection. Data collection focusing on healing rates, occurrence of abscess and follow-up was performed on a regular basis of quality control and patient care. Data were retrospectively analyzed. RESULTS: Between July 2018 and January 2021, 12 patients (6 females, 6 males) with a mean age of 42.5 (range: 26-61) years underwent stem cell therapy. All patients had a minimum of one complex fistula, including patients with two complex fistulas in 58.3% (7/12). Two of the 12 patients had horse-shoe fistula and 3 had one complex fistula. According to Parks classification, the majority of fistulas were transsphincteric (76%) or suprasphincteric (14%). All patients underwent removal of seton, fistula curettage, transanal closure of internal opening by suture (11/12) or mucosal flap (1/12) and stem cell injection. At a mean follow-up of 14.3 (range: 3-30) mo, a healing rate was documented in 66.7% (8/12); mean duration to achieve healing was 12 (range: 6-30) wk. Within follow-up, 4 patients required reoperation due to perianal abscess (33.3%). Focusing on patients with a minimum follow-up of 12 mo (6/12) or 24 mo (4/12), long-term healing rates were 66.7% (4/6) and 50.0% (2/4), respectively. CONCLUSION: Data of this single-center experience are promising but limited due to the small number of patients and the retrospective analysis.", "provenance": [ { "field": "population", "quote": "All patients with complex anal fistulas associated with Crohn's disease who were amenable for definite fistula closure within a defined observation period were potential candidates for stem cell injection" }, { "field": "intervention", "quote": "Local injection of darvadstrocel was performed as a standardized procedure under general anesthesia including single-shot antibiotic prophylaxis, removal of seton drainage, fistula curettage, closure of the internal openings and local stem cell injection." }, { "field": "comparator", "quote": "Data were retrospectively analyzed." }, { "field": "primaryOutcome", "quote": "Data collection focusing on healing rates, occurrence of abscess and follow-up was performed on a regular basis of quality control and patient care." }, { "field": "result", "quote": "a healing rate was documented in 66.7% (8/12); mean duration to achieve healing was 12 (range: 6-30) wk. Within follow-up, 4 patients required reoperation due to perianal abscess (33.3%)." }, { "field": "n", "quote": "12 patients (6 females, 6 males) with a mean age of 42.5 (range: 26-61) years underwent stem cell therapy." } ] }, { "id": "pmid:34218249", "pmid": "34218249", "doi": "10.12659/AJCR.931589", "nctId": null, "pmcid": "PMC8274364", "title": "Anorectal Abscess in a Patient with Neutropenia and Refractory Acute Myeloid Leukemia: To Operate or not to Operate?", "firstAuthor": "Ohzu", "multipleAuthors": true, "journal": "Am J Case Rep", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "man with neutropenia and acute myeloid leukemia with an anorectal abscess", "intervention": "surgical treatment of abscess (incision and drainage, later fistulotomy with debridement)", "comparator": "initial antibiotic treatment alone", "primaryOutcome": "resolution of abscess and fever", "result": "antibiotics failed; surgery (fistulotomy with debridement) eventually controlled infection and fever resolved", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot reliably show whether surgery works better than non-surgical treatment.", "directness": "direct", "limitations": "Single case report with no comparison group; patient had multiple confounding treatments including chemotherapy.", "followUp": "day 21 (fever resolution); patient later died of leukemia progression", "plainFinding": "Surgery helped when antibiotics failed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34218249/", "sourceText": "BACKGROUND Anorectal infections occur in 5% to 9% of patients with hematological malignancies, including acute myeloid leukemia, and cause febrile neutropenia and sepsis. Surgical treatments of anorectal abscesses tend to be avoided in patients with leukemia owing to persistent neutropenia and bleeding risks. CASE REPORT A 56-year-old man presented with an ischiorectal abscess. Preoperative laboratory test results revealed leukocytopenia and anemia. He was diagnosed with acute myeloid leukemia. He developed septic shock. Antibiotic treatment was ineffective, and fever persisted. One week later, the abscess was treated by incision and drainage. Two days later, induction chemotherapy was initiated. No pus was drained; cellulitis spread to both buttocks. Pain worsened, and oxycodone was administered. Achievement of complete remission failed. Reinduction therapy was started, followed by fistulotomy of the abscess with extensive debridement of cellulitis on day 6. Granulation was observed on day 17. The patient's fever resolved on day 21. Although hematopoietic recovery was observed, bone marrow examination demonstrated partial remission. Two additional courses of chemotherapy were administered. Abscess recurrence was not observed, even during febrile neutropenia. The surgical wound shrank to a skin defect along the gluteal cleft. He achieved complete remission and was transferred to another hospital, where he underwent 3 allogeneic stem cell transplants. He died of leukemia progression. CONCLUSIONS Surgical treatments can prevent fatal progression of anorectal abscess, even during neutropenia. Incision and drainage are suitable for fluctuant abscesses. For a non-fluctuant abscess aggravated by sepsis and cellulitis, it is worth considering more invasive surgical interventions, including debridement and fistulotomy.", "provenance": [ { "field": "n", "quote": "A 56-year-old man presented with an ischiorectal abscess." }, { "field": "population", "quote": "A 56-year-old man presented with an ischiorectal abscess. Preoperative laboratory test results revealed leukocytopenia and anemia. He was diagnosed with acute myeloid leukemia." }, { "field": "intervention", "quote": "followed by fistulotomy of the abscess with extensive debridement of cellulitis on day 6" }, { "field": "comparator", "quote": "Antibiotic treatment was ineffective, and fever persisted." }, { "field": "primaryOutcome", "quote": "The patient's fever resolved on day 21." }, { "field": "result", "quote": "Surgical treatments can prevent fatal progression of anorectal abscess, even during neutropenia." } ] }, { "id": "pmid:33447866", "pmid": "33447866", "doi": "10.1007/s00384-021-03845-6", "nctId": null, "pmcid": null, "title": "Needle aspiration treatment vs. incision of acute simple perianal abscess: randomized controlled study", "firstAuthor": "Sørensen", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2021, "design": "rct", "n": 98, "nField": "reported", "population": "adults with an acute simple perianal (anorectal) abscess", "intervention": "needle aspiration of the abscess plus a week of antibiotics (clindamycin)", "comparator": "conventional surgical incision and drainage", "primaryOutcome": "whether the abscess came back (recurrence)", "result": "abscess recurred much more often after needle aspiration (41%) than after incision drainage (15%)", "resultDirection": "harm", "quality": "moderate", "qualityWhy": "it was a randomized trial across three centers, but had under 100 patients and only one scheduled follow-up timepoint set per abscess type", "directness": "direct", "limitations": "abstract does not report blinding; relatively small sample size", "followUp": "52 weeks", "plainFinding": "Needle draining failed more often than surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33447866/", "sourceText": "PURPOSE: Needle aspiration of an acute simple perianal abscess may be an alternative to conventional incision drainage with potential advantages in wound healing, functional outcome, and quality of life. The aim and objectives of the study are to compare the outcome of needle aspiration and postoperative antibiotics with that of conventional surgical incision drainage of acute perianal abscess. The primary outcome was abscess recurrence. Secondary outcomes were fistula formation, wound healing, quality of life, and fecal continence. METHODS: This is a three-center randomized controlled trial, including adults with acute perianal abscess. The needle aspiration group received clindamycin for one week postoperatively. All included patients were scheduled for a follow-up at 2, 12, and 52 weeks postoperatively including physical examination, quality of life assessment (SF 36 questionnaire), and fecal continence (Wexner score). RESULTS: A total of 98 patients were included. The recurrence rate was 41% in needle aspiration and 15% in incision drainage, with HR of 3.033 (p = 0.014). Fistula formation was 15% without significant difference between the groups. There was no significant difference in wound healing, quality of life, or fecal incontinence scores. CONCLUSION: Needle aspiration with postoperative antibiotics cannot be recommended as an alternative for surgical incision in the treatment of acute perianal abscess. TRIAL REGISTRATION NUMBER: ClinicalTrials.org with identification number NCT02585141, initial release on 15 October 2015.", "provenance": [ { "field": "population", "quote": "adults with acute perianal abscess" }, { "field": "intervention", "quote": "needle aspiration and postoperative antibiotics" }, { "field": "comparator", "quote": "conventional surgical incision drainage" }, { "field": "primaryOutcome", "quote": "The primary outcome was abscess recurrence." }, { "field": "result", "quote": "The recurrence rate was 41% in needle aspiration and 15% in incision drainage, with HR of 3.033 (p = 0.014)." }, { "field": "n", "quote": "A total of 98 patients were included." }, { "field": "followUp", "quote": "follow-up at 2, 12, and 52 weeks postoperatively" } ] }, { "id": "pmid:33040321", "pmid": "33040321", "doi": "10.1007/s12664-020-01054-7", "nctId": null, "pmcid": null, "title": "Long-term outcomes in perianal fistulizing Crohn's disease in a resource-limited setting: A cohort analysis", "firstAuthor": "Vuyyuru", "multipleAuthors": true, "journal": "Indian J Gastroenterol", "year": 2020, "design": "retrospective", "n": 65, "nField": "reported", "population": "patients with perianal fistula due to Crohn's disease", "intervention": "medical therapy (immunomodulators and biological drugs)", "comparator": "fistula surgery or fecal diversion surgery", "primaryOutcome": "complete closure of the perianal fistula", "result": "complete response rates were 25% with immunomodulators, 42.8% with fistula surgery, 39.5% with biologicals, and 45.4% with diversion, but relapse was highest after surgery; absence of an abscess predicted long-term complete closure", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a small, retrospective, single-setting cohort of Crohn's fistula patients, not a controlled study of abscess treatment itself.", "directness": "indirect", "limitations": "Retrospective record review, resource-limited single-center setting, and the study addresses fistula management in Crohn's disease rather than treatment of anorectal abscess as the primary question.", "followUp": "median duration of follow-up of 45 (IQR, 24-66) months", "plainFinding": "Looked at fistula surgery, not abscess care", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33040321/", "sourceText": "BACKGROUND: Perianal fistula is one of the most challenging complications of Crohn's disease (CD). We aimed to describe treatment response with surgical and medical therapies, and long-term complications. METHODS: We retrospectively analyzed records of patients with perianal fistulizing CD who were prospectively followed from January 2005 to December 2018. RESULTS: Among 807 patients, 81 (10%) had perianal fistula and 65 were included in the final analysis. The mean age of presentation was 27.4 ± 10.3 years, and 78.5% were males with a median duration of follow-up of 45 (IQR, 24-66) months. 75.4% (n = 49) had complex fistulae. 55.4% (n = 36) of patients received multiple courses (> 5 courses) of antibiotics. Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively. The relapse rate was highest after fistula surgery (52.6%). 44.6% of patients received medical (immunomodulators-21 and biologicals-8) whereas 46.1% received surgery as the first-line therapy. The absence of perianal abscess was associated with complete fistula closure. One patient developed malignancy and 4 (6.1%) died at the end of follow-up. Among the patients (n = 28) who received biologicals, TB reactivation occurred in one patient (3.5%). CONCLUSION: Medical therapy should be offered as first-line therapy, and immunomodulators can be considered when patients cannot afford biologicals. Surgery offers temporary improvement and is associated with high relapse rates. Absence of perianal abscess predicts long-term complete fistula closure.", "provenance": [ { "field": "n", "quote": "65 were included in the final analysis" }, { "field": "population", "quote": "We retrospectively analyzed records of patients with perianal fistulizing CD who were prospectively followed from January 2005 to December 2018" }, { "field": "intervention", "quote": "Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively" }, { "field": "comparator", "quote": "Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively" }, { "field": "primaryOutcome", "quote": "The absence of perianal abscess was associated with complete fistula closure" }, { "field": "result", "quote": "Complete response rates with immunomodulators, fistula surgery, biologicals, and diversion were 25%, 42.8%, 39.5%, and 45.4%, respectively. The relapse rate was highest after fistula surgery (52.6%)" }, { "field": "result", "quote": "Absence of perianal abscess predicts long-term complete fistula closure" }, { "field": "followUp", "quote": "median duration of follow-up of 45 (IQR, 24-66) months" } ] }, { "id": "pmid:32785778", "pmid": "32785778", "doi": "10.1007/s00383-020-04728-7", "nctId": null, "pmcid": null, "title": "Management of perianal abscesses in infants without general anaesthesia: a systematic review of the literature", "firstAuthor": "Stokes", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2020, "design": "systematic-review", "n": 1049, "nField": "reported", "population": "infants younger than 24 months with perianal abscesses", "intervention": "treatment of the abscess without general anaesthesia (antibiotics, baths, needle drainage, local anaesthesia drainage, etc.)", "comparator": "later need for drainage under general anaesthesia", "primaryOutcome": "number of infants who ended up needing general anaesthesia after being treated without it first", "result": "75.3% healed completely without further treatment; 23.2% had recurrence or progressed to a fistula; only 5.6% eventually needed general anaesthesia", "resultDirection": "benefit", "quality": "low", "qualityWhy": "The evidence comes mostly from retrospective case series with no randomized trials, so the findings are not very reliable.", "directness": "indirect", "limitations": "No randomized controlled trials; mostly retrospective cohort studies with varied treatments and lack of standardized care.", "followUp": "", "plainFinding": "Most infants healed without surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32785778/", "sourceText": "Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA). This review aims to assess outcomes following management of perianal abscesses without GA in infants less than 24 months old. We aim to identify the success of management without GA. Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE and PubMed. Studies including infants less than 24 months with perianal abscesses managed without GA were reviewed. The primary outcome was the number of patients requiring GA following initial management without GA. Secondary outcomes included rates of recurrent perianal abscesses, rates of progression to FIA and time to cure. Nine studies, involving 1049 infants less than 24 months old met inclusion criteria. A total of 1039 (99.0%) were males. Study design consisted of one prospective case series of 18 patients, and eight retrospective cohort studies. There were no randomized control trials. A total of 1037 (98.9%) patients were initially managed without GA. Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic. Treatment modalities included antibiotics, regular baths, needle aspiration, incision and drainage under local anaesthesia, hainosankyuto and fibroblast growth factor. A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA. All patients who required a subsequent general anaesthetic had progressed to FIA. Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants, with more than 75% healing completely. Further research aimed at standardizing care and confirming the safety and efficacy of initial non-operative management are warranted, and may potentially reduce the number of unnecessary initial and subsequent clinical interventions.", "provenance": [ { "field": "population", "quote": "infants less than 24 months old" }, { "field": "intervention", "quote": "management of perianal abscesses without GA in infants less than 24 months old" }, { "field": "comparator", "quote": "The primary outcome was the number of patients requiring GA following initial management without GA." }, { "field": "primaryOutcome", "quote": "The primary outcome was the number of patients requiring GA following initial management without GA." }, { "field": "result", "quote": "A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA." }, { "field": "result", "quote": "Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic." }, { "field": "n", "quote": "Nine studies, involving 1049 infants less than 24 months old met inclusion criteria." }, { "field": "limitations", "quote": "There were no randomized control trials." }, { "field": "quality", "quote": "Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants" } ] }, { "id": "pmid:32740696", "pmid": "32740696", "doi": "10.1007/s00423-020-01941-9", "nctId": null, "pmcid": null, "title": "Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials", "firstAuthor": "Mohamedahmed", "multipleAuthors": true, "journal": "Langenbecks Arch Surg", "year": 2021, "design": "meta-analysis", "n": 485, "nField": "reported", "population": "patients with cutaneous abscess (including some with anorectal abscess) who had incision and drainage", "intervention": "incision and drainage of the abscess followed by packing of the cavity", "comparator": "incision and drainage of the abscess without packing of the cavity", "primaryOutcome": "abscess coming back, need for a second procedure, or forming an abnormal tunnel (fistula)", "result": "no significant difference between packing and no packing for recurrence, fistula, or need for a second procedure", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "it pools only eight trials with 485 patients and the authors' own additional analysis says the results are not conclusive and could be missing a true difference.", "directness": "indirect", "limitations": "Trial Sequential Analysis showed the meta-analysis was not conclusive and recurrence results were subject to type 2 error; both groups still underwent surgical incision and drainage rather than a non-surgical treatment.", "followUp": "", "plainFinding": "Packing didn't help after drainage.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32740696/", "sourceText": "AIMS: To evaluate comparative outcomes of incision and drainage of cutaneous abscess with and without packing of the abscess cavity. METHODS: A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing were included. Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis A Trial Sequential Analysis was conducted to determine the robustness of the findings. RESULTS: Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included. There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups. The results remained unchanged on sub-group analyses for ano-rectal abscess, paediatric patients, adult patients, and the use of antibiotics. The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error. CONCLUSION: Incision and drainage of cutaneous abscess with or without packing have comparable outcomes. However, considering the cost and post-operative pain associated with packing, performing the procedure without packing of the abscess cavity may be more favourable. The findings of the better quality ongoing RCTs may provide stronger evidence in favour of packing or non-packing.", "provenance": [ { "field": "n", "quote": "Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included." }, { "field": "population", "quote": "all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing were included" }, { "field": "population", "quote": "The results remained unchanged on sub-group analyses for ano-rectal abscess, paediatric patients, adult patients, and the use of antibiotics." }, { "field": "intervention", "quote": "incision and drainage of cutaneous abscess with and without packing" }, { "field": "comparator", "quote": "incision and drainage of cutaneous abscess with and without packing" }, { "field": "primaryOutcome", "quote": "Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis" }, { "field": "result", "quote": "There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups." }, { "field": "limitations", "quote": "The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error." } ] }, { "id": "pmid:32312918", "pmid": "32312918", "doi": "10.5604/01.3001.0013.8158", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in children - evaluation of treatment efficacy. Is it possible to avoid recurrence?", "firstAuthor": "Bałaż", "multipleAuthors": true, "journal": "Pol Przegl Chir", "year": 2020, "design": "retrospective", "n": 24, "nField": "reported", "population": "infants and children with perianal abscess and fistula-in-ano", "intervention": "minimally invasive treatment (sitz baths, antibiotics, or incision and drainage) without definitive fistula surgery", "comparator": "fistulotomy and fistulectomy surgery to treat the underlying fistula", "primaryOutcome": "recurrence of perianal abscess and fecal incontinence", "result": "patients treated with fistulotomy had no recurrence or incontinence, while those previously managed with incision and drainage elsewhere had more severe disease, needed further surgery, longer antibiotics and hospital stay", "resultDirection": "harm", "quality": "low", "qualityWhy": "This is a small, retrospective study with only 24 patients and no randomization, so the comparison between groups may be biased.", "directness": "indirect", "limitations": "Retrospective design, small sample size, and comparison groups defined by where patients were first treated rather than random assignment.", "followUp": "", "plainFinding": "Surgery beat minimally invasive treatment for recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32312918/", "sourceText": "INTRODUCTION: Perianal abscess and fistula-in-ano are common findings in infants and children. The perianal abscess is usually a manifestation of a fistula-in-ano. Experience of our center indicates general lack of knowledge of the origin of the abscess and therefore, it is usually treated by incision and drainage, which leads to repeated recurrences. AIM: We aimed to present the optimal management of fistula-in-ano and perianal abscess in order to reduce or even eliminate the risk of recurrence. MATERIAL AND METHODS: The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015. Patients were divided into two groups: group I (50%) was primary treated in our center, while group II had undergone prior surgical interventions in other hospitals. Fistula-in-ano was intraoperatively identified in all patients (100%) and fistulotomy was performed. RESULTS: No fecal incontinence or recurrence of perianal abscess were observed in any of our patients. In group II, the disorder was associated with severe inflammation, some patients underwent an additional surgical intervention, such as incision and drainage of an extensive buttock's abscess; patients required longer antibiotic therapy and prolonged hospitalization. CONCLUSION: Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate. Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess.", "provenance": [ { "field": "population", "quote": "Perianal abscess and fistula-in-ano are common findings in infants and children." }, { "field": "n", "quote": "The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015." }, { "field": "intervention", "quote": "Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate." }, { "field": "comparator", "quote": "Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess." }, { "field": "primaryOutcome", "quote": "No fecal incontinence or recurrence of perianal abscess were observed in any of our patients." }, { "field": "result", "quote": "In group II, the disorder was associated with severe inflammation, some patients underwent an additional surgical intervention, such as incision and drainage of an extensive buttock's abscess; patients required longer antibiotic therapy and prolonged hospitalization." } ] }, { "id": "pmid:31559720", "pmid": "31559720", "doi": "10.24953/turkjped.2019.01.007", "nctId": null, "pmcid": null, "title": "The pathogens and curative effects analysis of perianal abscess of infants under 3 months", "firstAuthor": "Zhu", "multipleAuthors": true, "journal": "Turk J Pediatr", "year": 2019, "design": "retrospective", "n": 66, "nField": "reported", "population": "infants under 3 months old with perianal (anorectal) abscess", "intervention": "surgical incision of the abscess along with antibiotics matched to the bacteria found", "comparator": "adults with perianal abscess treated the same way (historical comparison group)", "primaryOutcome": "rate of anal fistula complication after abscess incision", "result": "after incision, 6.6% of infants developed an anal fistula compared with 60.3% of adults, a significant difference", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a small retrospective chart review comparing infants to a historical adult group, with no comparison to non-surgical treatment and no randomization.", "directness": "indirect", "limitations": "retrospective design, no control group treated without surgery, comparison to adults rather than to a non-surgical approach", "followUp": "", "plainFinding": "Surgery plus antibiotics recommended, not non-surgical treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31559720/", "sourceText": "Zhu Y, Xu F. The pathogens and curative effects analysis of perianal abscess of infants under 3 months. Turk J Pediatr 2019; 61: 40-43. In order to guide clinical treatment for perianal abscess of young infants, the characteristics of pathogens and curative effects analysis were conducted. Bacterial culture results, antibiotics susceptibility tests and curative effects of abscess incision were retrospectively analyzed in 66 cases of perianal abscess of infants under 3 months. There were 48 cases of Klebsiella pneumoniae, 7 cases of Staphylococcus, 6 cases of Escherichia coli, 5 cases of Proteus in the pathogen culture results. Klebsiella pneumoniae, the predominant pathogen, was susceptible to most antibiotics, especially to imipenem, cefoperazonesulbactam and amikacin with low drug resistance rates. However, high drug resistance rates were found to ampicillin and nitrofurantion. After abscess incision, the complication rate of anal fistula was 6.6％ in infants under 3 months and 60.3％ in the adult group. There was significant difference P＜0.01. In conclusion, Klebsiella pneumoniae was the most common pathogen in perianal abscess of infants under 3 months and was commonly resistant to ampicillin and nitrofurantion. Since perianal abscess of infants under 3 months is a self-limited disorder, simple surgical intervention and synchronous sensitive antibiotic administration are suggested as the optimal management.", "provenance": [ { "field": "population", "quote": "66 cases of perianal abscess of infants under 3 months" }, { "field": "intervention", "quote": "simple surgical intervention and synchronous sensitive antibiotic administration are suggested as the optimal management" }, { "field": "comparator", "quote": "60.3％ in the adult group" }, { "field": "primaryOutcome", "quote": "the complication rate of anal fistula was 6.6％ in infants under 3 months and 60.3％ in the adult group" }, { "field": "result", "quote": "After abscess incision, the complication rate of anal fistula was 6.6％ in infants under 3 months and 60.3％ in the adult group. There was significant difference P＜0.01." }, { "field": "n", "quote": "66 cases of perianal abscess of infants under 3 months" } ] }, { "id": "pmid:31469939", "pmid": "31469939", "doi": "10.1111/ped.13996", "nctId": null, "pmcid": null, "title": "Perianal abscess in infants: Amenable to conservative treatment in selected cases", "firstAuthor": "Samuk", "multipleAuthors": true, "journal": "Pediatr Int", "year": 2019, "design": "case-series", "n": 19, "nField": "reported", "population": "infants under 2 years old with perianal abscess", "intervention": "conservative treatment (antibiotics, without surgery) for selected abscess cases", "comparator": "surgical drainage (historical/alternative approach, not a formal comparison group)", "primaryOutcome": "whether surgical drainage was ultimately needed", "result": "76.4% of infants avoided surgery, though 15.7% eventually required surgical drainage and recurrence occurred in some", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small, retrospective review of selected patients without a control group, so it can't reliably prove conservative treatment works as well as surgery.", "directness": "direct", "limitations": "Retrospective design, small sample, selection of 'suitable' cases only, two patients lost to follow-up, high recurrence rate", "followUp": "22.4 months", "plainFinding": "Most avoided surgery with antibiotics.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31469939/", "sourceText": "BACKGROUND: Perianal abscess is a common surgical condition in daily pediatric practice. Management is a subject of controversy and a variety of approaches are practiced. While the most frequent approach is drainage with/without fistulotomy, the superiority of this approach and the place of conservative approach has not been established. The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants. METHODS: Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed. RESULTS: Criteria for a conservative approach were: spontaneous drainage into the anal canal (n = 8) or perianal skin (n = 4), and phlegmonous infiltrate with fluid collection detected on ultrasound (n = 7). Mean age at symptom onset was 8.4 months. Twelve patients were managed for the first time. Previous care in seven patients included 1-4 drainage procedures (n = 4), spontaneous drainage (n = 1) and antibiotics (n = 2). Five patients were on oral antibiotics at presentation. After diagnosis, 18 patients received i.v. antibiotics and one, oral antibiotics. Three patients (15.7%) ultimately required surgical drainage; two were lost to follow up. During follow up (mean, 22.4 months) four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously. Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up. CONCLUSIONS: Perianal abscess in infants is amenable to conservative management in selected cases. Avoiding surgical intervention is advantageous, especially given the high recurrence rate.", "provenance": [ { "field": "n", "quote": "Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed." }, { "field": "population", "quote": "Data of 19 patients aged <24 months treated conservatively for perianal abscess" }, { "field": "intervention", "quote": "evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants" }, { "field": "comparator", "quote": "the most frequent approach is drainage with/without fistulotomy" }, { "field": "primaryOutcome", "quote": "Three patients (15.7%) ultimately required surgical drainage" }, { "field": "result", "quote": "surgical intervention was prevented in 13/17 patients (76.4%) available for follow up" }, { "field": "followUp", "quote": "During follow up (mean, 22.4 months)" } ] }, { "id": "pmid:31184590", "pmid": "31184590", "doi": null, "nctId": null, "pmcid": null, "title": "Early-stage Management of Complex Wounds Using Negative Pressure Wound Therapy With Instillation and a Dressing With Through Holes", "firstAuthor": "Obst", "multipleAuthors": true, "journal": "Wounds", "year": 2019, "design": "case-series", "n": 6, "nField": "reported", "population": "patients with complex wounds including pressure ulcers, necrotizing soft tissue infection, perianal abscess, and abdominal wound", "intervention": "negative pressure wound therapy with instillation and dwell time using a dressing with through holes, plus antibiotics and surgical debridement when appropriate", "comparator": "none (case series, no comparison group)", "primaryOutcome": "progression of wound healing and formation of granulation tissue", "result": "wound healing progressed with no complications in all cases, but wounds were not followed to closure or grafting", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a tiny, uncontrolled case series of only 6 patients with mixed wound types, including just one perianal abscess, so it cannot show whether this therapy avoids surgery for anorectal abscess specifically.", "directness": "indirect", "limitations": "Small sample size, no control group, mixed wound types with only one perianal abscess case, patients also received antibiotics and debridement, and outcomes were not followed to full closure.", "followUp": "", "plainFinding": "Wound improved without surgery closure unknown.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31184590/", "sourceText": "INTRODUCTION: An early-stage decision clinicians often make in the management of complex wounds is which method of wound preparation will be appropriate for the patient. This decision can be affected by numerous wound and patient risk factors that present challenges and may make surgical debridement difficult in patients with complex wounds. Recently, negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a novel reticulated open-cell foam dressing with through holes (ROCF-CC) was shown to aid in the loosening and removal of thick exudate and nonviable tissue from wounds. OBJECTIVE: The authors present their experiences of using NPWTi-d with ROCF-CC, along with rationales for wound care decisions. MATERIALS AND METHODS: Patients received antibiotics and surgical debridement when appropriate. Therapy selection and parameters were based on a decision-tree model for wound care management that takes into consideration patient and wound information. Most patients received NPWTi-d with ROCF-CC for a duration of 5 to 8 days; however, 1 patient received NPWTi-d with ROCF-CC for more than 30 days due to the wound extent and severity. Therapy consisted of instilling saline or quarter-strength sodium hypochlorite solution with dwell times of 3 to 10 minutes, followed by 2 hours or 3.5 hours of NPWT either at -100 mm Hg or -125 mm Hg. RESULTS: There were 6 patients (3 men, 3 women; average age, 58.5 years) treated. Wound types included 3 pressure ulcers, 1 necrotizing soft tissue infection, 1 perianal abscess, and 1 large abdominal wound. Patient comorbidities included obesity, type 2 diabetes, and radiation therapy. In all cases, progression of wound healing was observed with no complications. This method produced viable granulation tissue and wound bed preparation; however, patients were not followed to closure or grafting. CONCLUSIONS: These cases help support the use of NPWTi-d with ROCF-CC as a viable option for wound care providers in the early-stage management of complex wounds.", "provenance": [ { "field": "n", "quote": "There were 6 patients (3 men, 3 women; average age, 58.5 years) treated." }, { "field": "population", "quote": "Wound types included 3 pressure ulcers, 1 necrotizing soft tissue infection, 1 perianal abscess, and 1 large abdominal wound." }, { "field": "intervention", "quote": "negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a novel reticulated open-cell foam dressing with through holes (ROCF-CC)" }, { "field": "comparator", "quote": "Patients received antibiotics and surgical debridement when appropriate." }, { "field": "primaryOutcome", "quote": "In all cases, progression of wound healing was observed with no complications." }, { "field": "result", "quote": "This method produced viable granulation tissue and wound bed preparation; however, patients were not followed to closure or grafting." } ] }, { "id": "pmid:30916172", "pmid": "30916172", "doi": "10.6061/clinics/2019/e638", "nctId": null, "pmcid": "PMC6438129", "title": "Epidemiology and outcomes of anal abscess in patients on chronic dialysis: a 14-year retrospective study", "firstAuthor": "Hsieh", "multipleAuthors": true, "journal": "Clinics (Sao Paulo)", "year": 2019, "design": "retrospective", "n": 43, "nField": "reported", "population": "chronic dialysis patients hospitalized for a first-time anal abscess", "intervention": "antibiotic treatment alone (no surgery)", "comparator": "surgical treatment for the abscess", "primaryOutcome": "in-hospital death, one-year death, and one-year recurrence", "result": "no significant difference in hospital stay, one-year survival, or recurrence between surgical and nonsurgical groups, but a trend toward better in-hospital survival with surgery", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "small retrospective study with only 43 patients, not randomized, so differences between groups could explain the results rather than the treatment itself", "directness": "indirect", "limitations": "retrospective chart review, small sample size, specific to chronic dialysis patients, and a non-significant trend favoring surgery (p=0.082) that could reflect chance", "followUp": "one-year", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30916172/", "sourceText": "OBJECTIVES: We conducted this retrospective study to elucidate the clinical presentation and outcomes of anal abscess in chronic dialysis patients. METHODS: We performed a chart review of patients who were hospitalized for anal abscess from Jan. 2002 to Dec. 2015. A total of 3,074 episodes of anal abscess were identified. Of these, 43 chronic dialysis patients with first-time anal abscess were enrolled. Patients were divided into a surgical group and a nonsurgical group according to the treatment received during hospitalization. The baseline characteristics, clinical findings, treatments and outcomes were obtained and analyzed. The endpoints of this study were in-hospital mortality, one-year mortality and one-year recurrence. RESULTS: Of the 43 patients, 27 (62.7%) received surgical treatment, and 16 (37.2%) received antibiotic treatment alone. There was no significant difference in age, sex, body mass index, smoking habits, comorbidities, or dialysis characteristics between the two groups. Perianal abscess was the most common type of anal abscess, and 39.5% of patients experienced fistula formation. Most patients had mixed aerobic and anaerobic flora. Our data demonstrate that there was no significant difference in hospital stay, one-year survival or recurrence rate between the surgical group and nonsurgical group. However, there was a trend toward better in-hospital survival in patients who received surgical treatment (p=0.082). CONCLUSION: In chronic dialysis patients with anal abscess, there was no statistically significant difference in clinical presentation and outcomes between the surgical and nonsurgical groups, although the surgical group had a trend of better in-hospital survival.", "provenance": [ { "field": "n", "quote": "43 chronic dialysis patients with first-time anal abscess were enrolled" }, { "field": "population", "quote": "chronic dialysis patients" }, { "field": "intervention", "quote": "16 (37.2%) received antibiotic treatment alone" }, { "field": "comparator", "quote": "27 (62.7%) received surgical treatment" }, { "field": "primaryOutcome", "quote": "The endpoints of this study were in-hospital mortality, one-year mortality and one-year recurrence." }, { "field": "result", "quote": "there was no significant difference in hospital stay, one-year survival or recurrence rate between the surgical group and nonsurgical group. However, there was a trend toward better in-hospital survival in patients who received surgical treatment (p=0.082)." } ] }, { "id": "pmid:30799811", "pmid": "30799811", "doi": null, "nctId": null, "pmcid": null, "title": "[Perianal abscess after anal intercourse should raise suspicion of rectal gonorrhoeae infection]", "firstAuthor": "Kanstrup", "multipleAuthors": true, "journal": "Ugeskr Laeger", "year": 2019, "design": "case-series", "n": 1, "nField": "reported", "population": "young man with anal pain and fever after anal sex, found to have rectal gonorrhoea", "intervention": "surgical incision of the abscess plus antibiotics for gonorrhoea", "comparator": "none", "primaryOutcome": "healing of abscess and resolution of suspected fistula", "result": "abscess was drained surgically and treated with antibiotics; six weeks later ultrasound showed scarring but no fistula", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether surgery can be avoided", "directness": "indirect", "limitations": "single case report; abscess was treated with surgery, not used to test avoiding surgery; no comparison group", "followUp": "six weeks", "plainFinding": "Surgery plus antibiotics healed abscess", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30799811/", "sourceText": "Neisseria gonorrhoeae infection is a sexually transmitted disease. Rectal gonorrhoea is often asymptomatic, the most common symptoms are anal pain, bleeding and purulent discharge. This case report describes a younger man, who experienced increasing anal pain and later fever after anal intercourse. N. gonorrhoeae infection was verified, before a clinical examination revealed a perianal abscess. During incision of the abscess an anal fistula was suspected, and six weeks after primary surgery and treatment with relevant antibiotics, transanal ultrasonography showed perianal scarring and no signs of anocutaneous fistula.", "provenance": [ { "field": "n", "quote": "This case report describes a younger man" }, { "field": "population", "quote": "a younger man, who experienced increasing anal pain and later fever after anal intercourse. N. gonorrhoeae infection was verified, before a clinical examination revealed a perianal abscess" }, { "field": "intervention", "quote": "six weeks after primary surgery and treatment with relevant antibiotics" }, { "field": "comparator", "quote": "treatment with relevant antibiotics" }, { "field": "primaryOutcome", "quote": "transanal ultrasonography showed perianal scarring and no signs of anocutaneous fistula" }, { "field": "result", "quote": "six weeks after primary surgery and treatment with relevant antibiotics, transanal ultrasonography showed perianal scarring and no signs of anocutaneous fistula" } ] }, { "id": "pmid:30165543", "pmid": "30165543", "doi": "10.1093/ecco-jcc/jjy120", "nctId": null, "pmcid": null, "title": "Significant Medical and Surgical Morbidity in Perianal Crohn's Disease: Results from a Territory-Wide Study", "firstAuthor": "Mak", "multipleAuthors": true, "journal": "J Crohns Colitis", "year": 2018, "design": "registry", "n": 283, "nField": "reported", "population": "adults with Crohn's disease who had perianal involvement (including fistulas and abscesses), from a Hong Kong IBD registry", "intervention": "antibiotics and biologic drugs used to manage perianal Crohn's disease", "comparator": "surgical procedures (including abscess drainage, defunctioning surgery, proctectomy)", "primaryOutcome": "how often patients eventually needed biologics versus surgery over time", "result": "most patients still ended up needing surgery despite multiple courses of antibiotics, with surgery probability reaching about 78% by 8 years", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "this is a retrospective registry study of a specific Crohn's disease population, not a controlled comparison of abscess treatments, so it gives only indirect, uncontrolled evidence.", "directness": "indirect", "limitations": "retrospective registry design, no control group, mixes fistula and abscess cases together, and focuses on Crohn's disease patients rather than typical anorectal abscess patients", "followUp": "106 months", "plainFinding": "Most still needed surgery eventually.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30165543/", "sourceText": "BACKGROUND: The presence of perianal fistulas in Crohn's disease [CD] denotes increased disease aggressiveness. We studied the epidemiology and clinical outcomes of perianal CD [PCD] using the Hong Kong territory-wide IBD Registry [HKIBDR]. METHODS: Consecutive patients with PCD were identified from the HKIBDR, and disease characteristics, treatments, and outcomes were analysed. The risks for medical and surgical therapies were assessed using Kaplan-Meier analysis. RESULTS: Among 981 patients with CD with 10530 patient-years of follow-up, 283 [28.8%] had perianal involvement, of which 120 [42.4%] were as first presentation. The mean age at diagnosis of PCD was 29.1 years, and 78.8% were male. The median follow-up duration was 106 months (interquartile range [IQR]: 65-161 months]. Perianal fistula [84.8%] and perianal abscess [52.7%] were the two commonest forms. Male, younger age at diagnosis of CD, and penetrating phenotypes were associated with development of PCD in multivariate analysis. Of 242 patients with fistulizing PCD, 70 [29.2%] required ≥5 courses of antibiotics, and 98 [40.5%] had ≥2 surgical procedures. Nine patients required defunctioning surgery and 4 required proctectomy. Eighty-four patients [34.7%] received biologics. Cumulative probabilities for use of biologics were 4.7%, 5.8%, and 8.6% at 12 months, 36 months, and 96 months, respectively, while the probabilities for surgery were 67.2%, 71.6%, and 77.7%, respectively. Five mortalities were recorded, including 2 cases of anal cancer, 2 CD-related complications, and one case of pneumonia. CONCLUSION: Over 40% of CD patients presented with perianal disease at diagnosis. Patients with PCD had poor outcome, with young age of onset, multiple antibiotic use, and repeated surgery.", "provenance": [ { "field": "population", "quote": "Consecutive patients with PCD were identified from the HKIBDR" }, { "field": "n", "quote": "283 [28.8%] had perianal involvement" }, { "field": "intervention", "quote": "70 [29.2%] required ≥5 courses of antibiotics" }, { "field": "intervention", "quote": "Eighty-four patients [34.7%] received biologics" }, { "field": "comparator", "quote": "98 [40.5%] had ≥2 surgical procedures" }, { "field": "comparator", "quote": "Nine patients required defunctioning surgery and 4 required proctectomy" }, { "field": "primaryOutcome", "quote": "Cumulative probabilities for use of biologics were 4.7%, 5.8%, and 8.6% at 12 months, 36 months, and 96 months, respectively, while the probabilities for surgery were 67.2%, 71.6%, and 77.7%, respectively." }, { "field": "result", "quote": "Patients with PCD had poor outcome, with young age of onset, multiple antibiotic use, and repeated surgery." } ] }, { "id": "pmid:30086744", "pmid": "30086744", "doi": "10.1186/s12893-018-0389-0", "nctId": null, "pmcid": "PMC6081846", "title": "SECCA procedure for anal incontinence and antibiotic treatment: a case report of anal abscess", "firstAuthor": "Mandolfino", "multipleAuthors": true, "journal": "BMC Surg", "year": 2018, "design": "case-series", "n": 1, "nField": "reported", "population": "a 66-year-old woman with gas and fecal incontinence who developed an anal abscess after a SECCA radiofrequency procedure", "intervention": "a full antibiotic course of at least 6 days after the SECCA procedure", "comparator": "a short-term 24-hour antibiotic therapy", "primaryOutcome": "occurrence of anal abscess after the SECCA procedure", "result": "the authors suggest a longer antibiotic course may reduce the chance of abscess, based on this single case", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "it is a single case report with no comparison group, so it cannot show whether antibiotics alone can treat an abscess", "directness": "indirect", "limitations": "single case report; no control group; suggestion is speculative, not tested", "followUp": "", "plainFinding": "Longer antibiotics may prevent abscess.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30086744/", "sourceText": "BACKGROUND: Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter. CASE PRESENTATION: We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years. CONCLUSIONS: The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess. We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.", "provenance": [ { "field": "population", "quote": "a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years" }, { "field": "intervention", "quote": "administering antibiotic therapy to patients and to run a full course of at least 6 days" }, { "field": "comparator", "quote": "rather than a short-term (24 h) therapy" }, { "field": "primaryOutcome", "quote": "to minimize the incidence of this complication" }, { "field": "result", "quote": "We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy" }, { "field": "n", "quote": "a 66-year-old woman" } ] }, { "id": "pmid:31559351", "pmid": "31559351", "doi": "10.23922/jarc.2018-009", "nctId": null, "pmcid": "PMC6752149", "title": "Japanese Practice Guidelines for Anal Disorders II. Anal fistula", "firstAuthor": "Yamana", "multipleAuthors": false, "journal": "J Anus Rectum Colon", "year": 2018, "design": "guideline", "n": null, "nField": "not-reported", "population": "people with anorectal (anal) abscess or fistula", "intervention": "antibiotics or incision and drainage for anal abscess", "comparator": "surgery for anal fistula", "primaryOutcome": "whether the condition resolves without surgical treatment", "result": "As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas.", "resultDirection": "no-benefit", "quality": "very-low", "qualityWhy": "This is a general practice guideline summarizing common knowledge and expert recommendations, not a study with original patient data or statistics.", "directness": "indirect", "limitations": "The abstract is a general guideline summary without specific patient numbers, study design details, or outcome data; it mainly addresses anal fistula rather than abscess alone.", "followUp": "", "plainFinding": "Surgery usually needed, rarely resolves alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31559351/", "sourceText": "Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.", "provenance": [ { "field": "population", "quote": "Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever." }, { "field": "intervention", "quote": "Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage." }, { "field": "comparator", "quote": "As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas." }, { "field": "primaryOutcome", "quote": "As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas." }, { "field": "result", "quote": "As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas." } ] }, { "id": "pmid:29868530", "pmid": "29868530", "doi": "10.3389/fped.2018.00143", "nctId": null, "pmcid": "PMC5964207", "title": "Congenital Perirectal Dermoid Cyst: A Rare Cause of Complex, Recurrent Pediatric Fistula-in-ano", "firstAuthor": "Barry", "multipleAuthors": true, "journal": "Front Pediatr", "year": 2018, "design": "case-series", "n": 1, "nField": "reported", "population": "an 8-year-old boy with recurrent anal fistula", "intervention": "standard treatments for fistula-in-ano (not specified in detail)", "comparator": "none", "primaryOutcome": "resolution of the fistula/abscess", "result": "the fistula was complex and recurrent, caused by a rare congenital cyst, and did not resolve with standard treatment", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether non-surgical treatment generally works", "directness": "indirect", "limitations": "single case report of an unusual underlying cause (congenital dermoid cyst), not representative of typical anorectal abscess", "followUp": "", "plainFinding": "Rare case, surgery needed", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29868530/", "sourceText": "Perianal abscess and fistula-in-ano are well-described in the pediatric population. They are most common in infants less than 1 year of age and often resolve with oral antibiotics; occasionally they require drainage or fistulotomy. The etiology is commonly associated with cryptoglandular obstruction and subsequent infection, however alternative diagnoses should be considered in cases of recurrent abscesses and fistulae that are refractory to standard treatments. In this report, we present the case of an 8-year-old boy with a complex, recurrent fistula-in-ano that resulted from a rare congenital perirectal dermoid cyst.", "provenance": [ { "field": "population", "quote": "an 8-year-old boy with a complex, recurrent fistula-in-ano" }, { "field": "result", "quote": "resulted from a rare congenital perirectal dermoid cyst" }, { "field": "primaryOutcome", "quote": "complex, recurrent fistula-in-ano" }, { "field": "n", "quote": "an 8-year-old boy" }, { "field": "intervention", "quote": "often resolve with oral antibiotics; occasionally they require drainage or fistulotomy" }, { "field": "comparator", "quote": "alternative diagnoses should be considered in cases of recurrent abscesses and fistulae that are refractory to standard treatments" } ] }, { "id": "pmid:29608959", "pmid": "29608959", "doi": "10.1016/j.ijid.2018.03.016", "nctId": null, "pmcid": null, "title": "Clinical diagnostic and therapeutic aspects of 221 consecutive anorectal Chlamydia trachomatis and Neisseria gonorrhoeae sexually transmitted infections among men who have sex with men", "firstAuthor": "Lourtet Hascoet", "multipleAuthors": true, "journal": "Int J Infect Dis", "year": 2018, "design": "prospective-cohort", "n": 221, "nField": "reported", "population": "men who have sex with men with anorectal chlamydia or gonorrhoea infection (proctitis)", "intervention": "antibiotic treatment for the STI (azithromycin/ceftriaxone, excluding quinolones)", "comparator": "", "primaryOutcome": "clinical, diagnostic and therapeutic aspects of the infections, including rates of anal abscess and surgery", "result": "27 patients (13.9%) developed anal abscesses, and of these 14 (7.2% of the total) went on to have surgery for anal fistula", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a descriptive case series of STI patients without a control group comparing surgical versus non-surgical abscess care, so it cannot show whether abscess can be treated without surgery.", "directness": "indirect", "limitations": "Observational, no comparison group, focused on STI diagnosis/treatment rather than abscess management; abscess and surgery numbers are incidental findings.", "followUp": "", "plainFinding": "Most abscess patients avoided surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29608959/", "sourceText": "OBJECTIVES: Proctitis caused by Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are known as sexually transmitted infections (STI). This study describes their clinical, diagnostic and therapeutic aspects. METHODS: Between 01/2013-03/2015, all MSM consulting for proctitis at proctology Institute-Saint-Joseph's Hospital, Paris, were included. Demographic, past-medical history, STI status and medical treatment were collected. Detection of CT/NG was performed by Transcription-Mediated Amplification (TMA) and antimicrobial susceptibilities for Ng by agar diffusion method. RESULTS: On 441 rectal samples collected, 221 (50.1%) were positive: 109 Ct (49.3%), 70 Ng (31.7%), 42 positive for both etiologies (19%). Among Ng infections, no resistance was detected to azithromycin and ceftriaxone. However, 84 strains (43.2%) were resistant to fluoroquinolones. More than one episode was diagnosed for 10 (5.1%) and 12 (6.2%) patients with CT and NG infections respectively. Anal abscesses were found for 27 (13.9%) patients, and 14 (7.2%) of them underwent surgery for anal fistula. CONCLUSIONS: The prevalence of CT/NG anorectal infections described is high on symptomatic patients, and a significant level of abscess was reported. These results confirm the interest of the association of recommended antibiotics excluding quinolones. Prospective studies would be relevant on complicated forms of anorectal infections.", "provenance": [ { "field": "n", "quote": "On 441 rectal samples collected, 221 (50.1%) were positive" }, { "field": "population", "quote": "all MSM consulting for proctitis at proctology Institute-Saint-Joseph's Hospital, Paris, were included" }, { "field": "intervention", "quote": "the association of recommended antibiotics excluding quinolones" }, { "field": "primaryOutcome", "quote": "This study describes their clinical, diagnostic and therapeutic aspects." }, { "field": "result", "quote": "Anal abscesses were found for 27 (13.9%) patients, and 14 (7.2%) of them underwent surgery for anal fistula." } ] }, { "id": "pmid:29596040", "pmid": "29596040", "doi": "10.1089/sur.2017.225", "nctId": null, "pmcid": null, "title": "Comparative Study of Drainage and Antibiotics versus Drainage Only in the Management of Primary Subcutaneous Abscesses", "firstAuthor": "López", "multipleAuthors": true, "journal": "Surg Infect (Larchmt)", "year": 2018, "design": "rct", "n": 165, "nField": "reported", "population": "patients with skin abscesses needing drainage, including some perianal abscesses", "intervention": "antibiotics after incision and drainage", "comparator": "placebo after incision and drainage", "primaryOutcome": "abscess resolved by day 7", "result": "no significant difference in resolution between antibiotics and placebo", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a randomized trial, but it studied general skin abscesses (not specifically anorectal) and all patients still had surgical drainage, so it does not test surgery versus no-surgery.", "directness": "indirect", "limitations": "Both groups underwent surgical drainage; the study compares antibiotics vs placebo after drainage, not surgery vs no surgery, and perianal abscesses were only a subset of cases with uneven distribution between groups.", "followUp": "7 days", "plainFinding": "Antibiotics added nothing after drainage.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29596040/", "sourceText": "BACKGROUND: Skin and soft tissue infections are common problems dealt with in emergency departments and medical offices. It is routine practice to prescribe antibiotic agents after incision and drainage of cutaneous abscesses. However, current evidence does not support prescribing oral antibiotic agents after surgical debridement. The aim of the present study was to determine the actual role of antibiotic agents after drainage of cutaneous abscesses. PATIENTS AND METHODS: This was a prospective study of patients undergoing incision and drainage (I&D) of a subcutaneous abscess. Patients were randomly assigned either to receive antibiotic agents (group 1) or placebo (group 2) after I&D. The primary end point was resolution rate of the abscess at the seventh day. Secondary end points were pain at the seventh day and total time to full healing of the wound. P value <0.05 was considered statistically significant. RESULTS: One hundred sixty-five patients were included for analysis. Age, gender, body mass index (BMI), and comorbidities did not differ substantially between groups. Chest and peri-anal abscesses were statistically more frequent in group 2, whereas neck abscesses were more frequent in group 1 (p = 0.02). Leukocyte count was also statistically higher in group 1 (p = 0.005). Resolution rate was 96% in group 1 and 93% in group 2, with no statistical difference between both (p = 0.28). Neither pain at seventh day nor time to full healing differed statistically between groups. CONCLUSIONS: Antibiotic agents are not necessary for uncomplicated subcutaneous abscesses after I&D. These cases can be managed safely on an outpatient basis without any increase in morbidity.", "provenance": [ { "field": "n", "quote": "One hundred sixty-five patients were included for analysis." }, { "field": "population", "quote": "Chest and peri-anal abscesses were statistically more frequent in group 2" }, { "field": "intervention", "quote": "Patients were randomly assigned either to receive antibiotic agents (group 1) or placebo (group 2) after I&D." }, { "field": "comparator", "quote": "placebo (group 2) after I&D" }, { "field": "primaryOutcome", "quote": "The primary end point was resolution rate of the abscess at the seventh day." }, { "field": "result", "quote": "Resolution rate was 96% in group 1 and 93% in group 2, with no statistical difference between both (p = 0.28)." } ] }, { "id": "pmid:29126509", "pmid": "29126509", "doi": "10.1053/j.sempedsurg.2017.10.009", "nctId": null, "pmcid": null, "title": "Treatment of perianal Crohn's disease", "firstAuthor": "Zalieckas", "multipleAuthors": false, "journal": "Semin Pediatr Surg", "year": 2017, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with perianal Crohn's disease", "intervention": "multimodal approach to therapy including medical and surgical modalities", "comparator": "", "primaryOutcome": "managing symptoms while maintaining continence", "result": "abstract does not report a specific result; states treatment is less successful than in patients without Crohn's related perianal disease", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general review article with no study data, numbers, or specific outcomes reported, so it carries little weight for this question.", "directness": "indirect", "limitations": "no methodology, no data, no specific findings on abscess treatment without surgery are given", "followUp": "", "plainFinding": "No clear answer given.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29126509/", "sourceText": "Perianal Crohn's is a common manifestation of Crohn's disease. Primary manifestations of perianal disease mirror common anorectal conditions, however treatment is less successful than in those patients without Crohn's related perianal disease. A multimodal approach to therapy including medical and surgical modalities is often necessary. The goal of treatment is to manage symptoms while maintaining continence.", "provenance": [ { "field": "population", "quote": "Perianal Crohn's is a common manifestation of Crohn's disease." }, { "field": "intervention", "quote": "A multimodal approach to therapy including medical and surgical modalities is often necessary." }, { "field": "primaryOutcome", "quote": "The goal of treatment is to manage symptoms while maintaining continence." }, { "field": "result", "quote": "treatment is less successful than in those patients without Crohn's related perianal disease" } ] }, { "id": "pmid:28945635", "pmid": "28945635", "doi": "10.1097/MIB.0000000000001254", "nctId": null, "pmcid": null, "title": "Comparison of Stromal Vascular Fraction with or Without a Novel Bioscaffold to Fibrin Glue in a Porcine Model of Mechanically Induced Anorectal Fistula", "firstAuthor": "Dryden", "multipleAuthors": true, "journal": "Inflamm Bowel Dis", "year": 2017, "design": "animal", "n": 17, "nField": "reported", "population": "Pigs with surgically created anorectal fistulas (a model of Crohn's-related fistula, not human abscess)", "intervention": "Stromal vascular fraction (fat-derived cells) injected alone or combined with a bioabsorbable scaffold", "comparator": "Fibrin glue treatment of the fistula", "primaryOutcome": "Whether the fistula tract healed by week 2", "result": "All fistulas treated with cells plus scaffold healed, compared with only some treated with cells alone and none treated with fibrin glue", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a small animal experiment on surgically made fistulas, not a human study of abscess treatment, so it gives only indirect, low-certainty evidence.", "directness": "indirect", "limitations": "Small number of animals per group, a mechanically created fistula model in pigs rather than naturally occurring disease, and no human data; also studies fistula healing, not whether an abscess itself can be managed without surgery.", "followUp": "4 weeks", "plainFinding": "Cell-scaffold therapy healed fistulas in pigs", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28945635/", "sourceText": "BACKGROUND: Anorectal fistulas (ARFs) are a common, devastating, event in the life of a patient with Crohn's disease. ARFs occur in up to 50% of patients with Crohn's disease. Treatment begins with surgical drainage of the initial abscess, followed by antibiotic therapy, then anti-inflammatory medications. If medical therapy fails to close the fistula tract, surgical intervention is often pursued. Surgery incurs risk of incontinence because of sphincter injury. Increasingly, the role of cell-based therapy is being investigated in ARFs. We evaluated the role a bioabsorbable scaffold plays in delivering cell-based therapy using a porcine model of AFR. METHODS: ARFs were mechanically created and matured by setons. After 28 days, setons were removed; periaortic fat was harvested and processed for stromal vascular fraction (SVF). The cells were labeled with a membrane stain for later identification, then injected into the fistula or implanted through scaffold. Fistulas not treated with cells were injected with fibrin glue. Animals were monitored visually for healing at weeks 2 and 4, then euthanized to evaluate fistulas for histologic healing. RESULTS: All fistulas (6/6) treated with SVF + scaffolds healed by week 2, compared with only 4/6 with just SVF and 0/5 treated with fibrin glue. Scaffolds retained SVF within the fistula tract more readily than injection method and SVF+scaffold treatment accelerated the healing process. Robust neovascularization was also seen in fistulas treated with SVF+scaffold. No adverse events occurred. CONCLUSIONS: Scaffold technology may improve cell-based therapy healing rates for Crohn's ARFs. This advance should be investigated by human trials.", "provenance": [ { "field": "population", "quote": "ARFs were mechanically created and matured by setons." }, { "field": "intervention", "quote": "periaortic fat was harvested and processed for stromal vascular fraction (SVF). The cells were labeled with a membrane stain for later identification, then injected into the fistula or implanted through scaffold." }, { "field": "comparator", "quote": "Fistulas not treated with cells were injected with fibrin glue." }, { "field": "primaryOutcome", "quote": "Animals were monitored visually for healing at weeks 2 and 4, then euthanized to evaluate fistulas for histologic healing." }, { "field": "result", "quote": "All fistulas (6/6) treated with SVF + scaffolds healed by week 2, compared with only 4/6 with just SVF and 0/5 treated with fibrin glue." }, { "field": "n", "quote": "All fistulas (6/6) treated with SVF + scaffolds healed by week 2, compared with only 4/6 with just SVF and 0/5 treated with fibrin glue." }, { "field": "followUp", "quote": "Animals were monitored visually for healing at weeks 2 and 4" } ] }, { "id": "pmid:28066859", "pmid": "28066859", "doi": "10.1007/s10151-016-1578-4", "nctId": null, "pmcid": null, "title": "The long-term outcome of anti-TNF alpha therapy in perianal Crohn's disease", "firstAuthor": "Rayen", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2017, "design": "retrospective", "n": 75, "nField": "reported", "population": "adults with perianal Crohn's disease", "intervention": "anti-TNF alpha drug therapy", "comparator": "patients with different fistula types and prior treatment history (no drug comparator)", "primaryOutcome": "response to anti-TNF therapy (clinical, MRI healing, need for surgery)", "result": "73% of patients responded overall, but complete healing on MRI was rare, and those with prior abscess drainage were less likely to respond", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a retrospective single-center review without a control group, so it cannot reliably show whether treatment caused the outcomes.", "directness": "indirect", "limitations": "Retrospective design, single center, no control group, and the abstract notes MRI often did not confirm clinical healing.", "followUp": "", "plainFinding": "Drug helped symptoms, rarely cured fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28066859/", "sourceText": "BACKGROUND: The aim of the present study was to evaluate the long-term outcomes of anti-tumour necrosis factor alpha therapy in perianal Crohn's disease and identify factors predicting response to treatment. METHODS: Data from hospital clinical records and coding databases were retrospectively reviewed from a tertiary care hospital in Christchurch, New Zealand. The study included 75 adult patients with perianal Crohn's disease commenced on anti-tumour necrosis factor alpha therapy from January 2000 to December 2012. Response to treatment was determined from records relating to clinical evaluation, magnetic resonance imaging follow-up and whether further surgical intervention was required. RESULTS: 73% (55) of all patients and 38 of the 57 (67%) patients with perianal fistulas responded to anti-tumour necrosis factor alpha therapy. Patients with complex fistulas were less likely to improve as compared to patients without fistulising disease. Five of the 57 (13%) patients with perianal fistulas demonstrated complete healing on clinical evaluation; however, magnetic resonance imaging confirmed complete healing in only two. Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment [relative risk (RR) = 0.707 and 0.615, respectively; p = 0.03, p = 0.0001]. Responders were less likely to require follow-up surgery (RR = 0.658, p = 0.014) including ileostomy or proctectomy. CONCLUSIONS: Although anti-tumour necrosis factor alpha tends to improve symptoms of perianal Crohn's disease, in the long term, it rarely achieves complete healing. Perianal fistulising disease, a history of perianal abscess and antibiotic treatment are predictors of poor response to therapy.", "provenance": [ { "field": "n", "quote": "The study included 75 adult patients with perianal Crohn's disease commenced on anti-tumour necrosis factor alpha therapy from January 2000 to December 2012." }, { "field": "population", "quote": "75 adult patients with perianal Crohn's disease" }, { "field": "intervention", "quote": "anti-tumour necrosis factor alpha therapy" }, { "field": "comparator", "quote": "Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment" }, { "field": "primaryOutcome", "quote": "Response to treatment was determined from records relating to clinical evaluation, magnetic resonance imaging follow-up and whether further surgical intervention was required." }, { "field": "result", "quote": "73% (55) of all patients and 38 of the 57 (67%) patients with perianal fistulas responded to anti-tumour necrosis factor alpha therapy." }, { "field": "result", "quote": "Five of the 57 (13%) patients with perianal fistulas demonstrated complete healing on clinical evaluation; however, magnetic resonance imaging confirmed complete healing in only two." }, { "field": "result", "quote": "Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment [relative risk (RR) = 0.707 and 0.615, respectively; p = 0.03, p = 0.0001]." } ] }, { "id": "pmid:27079352", "pmid": "27079352", "doi": "10.1016/j.amjms.2015.11.012", "nctId": null, "pmcid": null, "title": "Infectious Diseases Perspective of Anorectal Abscess and Fistula-in-ano Disease", "firstAuthor": "Wright", "multipleAuthors": false, "journal": "Am J Med Sci", "year": 2016, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "patients with anorectal abscess and fistula-in-ano, mostly from common gut bacteria but some from unusual infections", "intervention": "antibiotic therapy combined with surgical incision and drainage, or antibiotics alone for unusual infections", "comparator": "surgical incision and drainage alone", "primaryOutcome": "healing time and recurrence rate", "result": "antibiotics added to surgery did not speed healing or lower recurrence for common cases, but antibiotics alone worked well for rare pathogen infections", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a review of mostly retrospective studies and case series rather than controlled trials, so the evidence is weak.", "directness": "direct", "limitations": "Abstract states data are derived primarily from prospective and retrospective trials and institutional case series, providing only an 'evidence level opinion' rather than controlled comparisons.", "followUp": "", "plainFinding": "Antibiotics alone don't replace surgery usually.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27079352/", "sourceText": "BACKGROUND: Anorectal abscess and fistula-in-ano is a rare disease with an exemplary prognosis. Most patients are diagnosed with cryptoglandular disease but unusual infections raise difficult antimicrobial management challenges. METHODS: All primary references identified in PubMed, EMBASE, the ISI Web of Knowledge database and the Cochrane Library, published between 1960 and 2015, using the keywords \"anorectal abscess,\" \"fistula-in-ano,\" \"perianal abscess,\" or \"perianal fistula\" or all, were uploaded into a database. The databases were also interrogated using keywords specific for each infection type studied. RESULTS: In all, 52 relevant primary medical publications were identified. There were also 4 relevant organizational standards guideline publications, 1 relevant review and 4 historical publications about the diagnosis and outcomes of anorectal abscess and fistula-in-ano with data derived primarily from prospective and retrospective trials as well as institutional case series to provide an evidence level opinion. The use of antimicrobial therapy in combination with surgical incision and drainage in the treatment of cryptoglandular disease has failed to improved healing times or reduce recurrences or both. Based on limited data, routine antimicrobial therapy may benefit patients with significant comorbid conditions, extensive cellulitis and systemic symptoms. For patients with unusual infecting pathogens (eg, Mycobacterium tuberculosis, Actinomyces species and Chlamydia species) outcomes are favorable with selected antimicrobial therapy agents of various durations. CONCLUSION: Surgical incision and drainage is the main treatment for anorectal abscess and fistula-in-ano, but a select group of patients with unusual infections benefit from tailored prolonged antimicrobial therapy with the overall recurrence rate remaining low.", "provenance": [ { "field": "population", "quote": "Most patients are diagnosed with cryptoglandular disease but unusual infections raise difficult antimicrobial management challenges." }, { "field": "intervention", "quote": "The use of antimicrobial therapy in combination with surgical incision and drainage in the treatment of cryptoglandular disease" }, { "field": "comparator", "quote": "Surgical incision and drainage is the main treatment for anorectal abscess and fistula-in-ano" }, { "field": "primaryOutcome", "quote": "has failed to improved healing times or reduce recurrences or both" }, { "field": "result", "quote": "The use of antimicrobial therapy in combination with surgical incision and drainage in the treatment of cryptoglandular disease has failed to improved healing times or reduce recurrences or both." }, { "field": "result", "quote": "For patients with unusual infecting pathogens (eg, Mycobacterium tuberculosis, Actinomyces species and Chlamydia species) outcomes are favorable with selected antimicrobial therapy agents of various durations." }, { "field": "limitations", "quote": "data derived primarily from prospective and retrospective trials as well as institutional case series to provide an evidence level opinion" } ] }, { "id": "pmid:26557835", "pmid": "26557835", "doi": "10.1159/000434664", "nctId": null, "pmcid": "PMC4608613", "title": "Medical Therapy of Perianal Crohn's Disease", "firstAuthor": "Klag", "multipleAuthors": true, "journal": "Viszeralmedizin", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with Crohn's disease who have fistulas or abscesses around the anus", "intervention": "antibiotics, immune-suppressing drugs, and anti-TNF biologic therapy", "comparator": "not clearly compared against surgery alone", "primaryOutcome": "healing or closure of perianal fistulas/abscesses", "result": "medical drugs can help close fistulas but the review says they should be combined with surgery, not replace it", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a narrative literature review of selected articles, not a controlled study, so it can't reliably show whether surgery can be avoided.", "directness": "indirect", "limitations": "non-systematic selection of 36 articles, no original patient data, and focuses on Crohn's-related fistulas rather than typical anorectal abscess without surgery", "followUp": "", "plainFinding": "Drugs help but surgery still used.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26557835/", "sourceText": "BACKGROUND: Development of perianal fistulas are a common feature of Crohn's disease (CD). Consequences are severe impairment of quality of life as well as potentially life-threatening complications like abscess formation or bacterial sepsis. Therefore, appropriate treatment is an important task in the management of CD. METHODS: This review describes the epidemiology, pathogenesis, diagnosis, and conservative medical treatment of perianal CD with regard to the available literature. In February 2015, a PubMed search was performed with the following terms (combined and separate): 'Crohn's disease management', 'Crohn's disease complications', 'perianal Crohn's disease', 'fistulizing Crohn's disease', 'perianal fistulas', 'fistula healing', 'fistula closure'. From the search results, 36 articles were chosen as core elements of this review. RESULTS: Pelvic magnetic resonance imaging and rectal endosonography are established diagnostic approaches to evaluate perianal fistulas in conjunction with endoscopy. Antibiotics, thiopurines, and calcineurin inhibitors are useful agents in the management of perianal CD. The availability of anti-TNF-alpha therapies has substantially changed the prospects and goals of medical treatment, and fistula healing seems to be possible in a substantial proportion of patients. CONCLUSION: Antibiotics and several immunosuppressive drugs have improved the treatment of fistulizing CD and should be combined with surgical measures.", "provenance": [ { "field": "population", "quote": "perianal fistulas are a common feature of Crohn's disease (CD)" }, { "field": "intervention", "quote": "Antibiotics, thiopurines, and calcineurin inhibitors are useful agents in the management of perianal CD." }, { "field": "comparator", "quote": "should be combined with surgical measures" }, { "field": "primaryOutcome", "quote": "fistula healing seems to be possible in a substantial proportion of patients" }, { "field": "result", "quote": "Antibiotics and several immunosuppressive drugs have improved the treatment of fistulizing CD and should be combined with surgical measures." } ] }, { "id": "pmid:26240046", "pmid": "26240046", "doi": null, "nctId": null, "pmcid": null, "title": "[Perianal abscesses in twins]", "firstAuthor": "Horsager", "multipleAuthors": true, "journal": "Ugeskr Laeger", "year": 2015, "design": "case-series", "n": 2, "nField": "reported", "population": "29-day-old twin baby boys with perianal abscesses", "intervention": "conservative (non-surgical) management", "comparator": "incision and drainage (surgery)", "primaryOutcome": "resolution of perianal abscess", "result": "", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a report of just two infants, so it cannot reliably show whether non-surgical treatment works.", "directness": "direct", "limitations": "Only two patients described; abstract does not report their treatment outcome, and aetiology and antibiotic effectiveness remain unproven.", "followUp": "", "plainFinding": "Outcome not reported in abstract.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26240046/", "sourceText": "Perianal abscesses (PA) are relatively common in children, especially in infants. The aetiology of PA is still unknown but several factors point toward a congenital aetiology: 1) it is almost exclusively seen in infants, 2) with a male predominance, 3) predilection sites at 3 and 9 o'clock, 4) the finding of abnormal Morgagni crypts and 5) aberrant epithelial lining. Traditionally, incision and drainage has been the treatment of choice, but several studies suggest conservative management. The effect of antibiotics has not been proven. In this case report we present two 29-day-old monozygous twin boys with PA.", "provenance": [ { "field": "n", "quote": "two 29-day-old monozygous twin boys with PA" }, { "field": "population", "quote": "two 29-day-old monozygous twin boys with PA" }, { "field": "intervention", "quote": "several studies suggest conservative management" }, { "field": "comparator", "quote": "Traditionally, incision and drainage has been the treatment of choice" }, { "field": "primaryOutcome", "quote": "In this case report we present two 29-day-old monozygous twin boys with PA." } ] }, { "id": "pmid:26050507", "pmid": "26050507", "doi": null, "nctId": null, "pmcid": null, "title": "[Surgical treatment for perianal Crohn's disease]", "firstAuthor": "Futami", "multipleAuthors": true, "journal": "Nihon Geka Gakkai Zasshi", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with perianal Crohn's disease (fistula, abscess, ulcers, etc.)", "intervention": "medications (antibiotics, immunosuppressants, anti-TNF) and surgical options such as fistulotomy, seton drainage, diverting stoma", "comparator": "different surgical techniques and medical therapy compared to each other", "primaryOutcome": "maintaining remission and anal function / symptom control", "result": "medications alone are hard to maintain long-term remission with; surgery is often needed but carries recurrence and incontinence risk, so the goal has shifted to reducing drainage rather than complete closure", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a narrative overview summarizing general treatment experience, not a controlled study, so it cannot reliably show whether abscess can be treated without surgery.", "directness": "indirect", "limitations": "Narrative review with no original data, no defined study population or outcome measures, and focused on fistula management rather than abscess specifically.", "followUp": "", "plainFinding": "No clear answer on abscess alone", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26050507/", "sourceText": "Perianal lesions are a frequent complication of Crohn's disease (CD) and include fistula, abscess, anal ulcer, skin tag, anal stricture, and carcinoma. Perianal fistula is the most commonly observed condition and exhibits multiple incidence and intractable characteristics. The starting point for the management of perianal fistula is an accurate diagnosis, which requires careful exploration during an EUA. The condition is treated with medications such as antibiotics, immunosuppressants, or anti-tumor necrosis factor agents. However, it is difficult to maintain long-term remission. Surgical therapy is selected according to the type of fistula and can include conventional fistulotomy, seton drainage, diverting stoma, and anorectal amputation. After fistulotomy, recurrence is frequent and there is an increased risk of incontinence. Seton drainage is the preferred treatment to improve symptoms and preserve anal function. Stoma is useful to relieve symptoms but difficult to indicate for young patients. The optimum treatment for perianal fistula associated with CD remains controversial. Currently, the goal of therapy for these patients has shifted from complete fistula closure to reducing drainage from the fistula to improve their quality of life. Ongoing careful management is important to control anal symptoms and maintain long-term anal function in the treatment of patients with CD, while monitoring them to detect possible progression to anorectal carcinoma.", "provenance": [ { "field": "population", "quote": "Perianal lesions are a frequent complication of Crohn's disease (CD) and include fistula, abscess, anal ulcer, skin tag, anal stricture, and carcinoma." }, { "field": "intervention", "quote": "The condition is treated with medications such as antibiotics, immunosuppressants, or anti-tumor necrosis factor agents." }, { "field": "intervention", "quote": "Surgical therapy is selected according to the type of fistula and can include conventional fistulotomy, seton drainage, diverting stoma, and anorectal amputation." }, { "field": "result", "quote": "However, it is difficult to maintain long-term remission." }, { "field": "result", "quote": "After fistulotomy, recurrence is frequent and there is an increased risk of incontinence." }, { "field": "result", "quote": "Currently, the goal of therapy for these patients has shifted from complete fistula closure to reducing drainage from the fistula to improve their quality of life." }, { "field": "comparator", "quote": "Seton drainage is the preferred treatment to improve symptoms and preserve anal function." }, { "field": "primaryOutcome", "quote": "Ongoing careful management is important to control anal symptoms and maintain long-term anal function in the treatment of patients with CD" } ] }, { "id": "pmid:25691848", "pmid": "25691848", "doi": "10.5217/ir.2015.13.1.85", "nctId": null, "pmcid": "PMC4316228", "title": "Perianal Abscess and Proctitis by Klebsiella pneumoniae", "firstAuthor": "Jeong", "multipleAuthors": true, "journal": "Intest Res", "year": 2015, "design": "case-series", "n": 1, "nField": "reported", "population": "61-year-old man with diabetes and history of alcohol abuse, with abdominal and anal pain", "intervention": "antibiotics alone (ciprofloxacin and metronidazole) initially, then surgery after worsening", "comparator": "", "primaryOutcome": "resolution of perianal/perirectal abscess and proctitis", "result": "Antibiotics alone did not resolve the infection; lesions worsened and surgery with drainage was required, after which he improved", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a single case report, so it cannot reliably show whether non-surgical treatment works in general.", "directness": "indirect", "limitations": "Single patient case report with an unusual, invasive bacterial cause (ESBL-producing K. pneumoniae) in a patient with diabetes and alcoholism, limiting generalizability.", "followUp": "", "plainFinding": "Antibiotics failed; needed surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25691848/", "sourceText": "Klebsiella pneumoniae (K. pneumoniae) can at times cause invasive infections, especially in patients with diabetes mellitus and a history of alcohol abuse. A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks. After admission, he underwent sigmoidoscopy, which revealed multiple ulcerations with yellowish exudate in the rectum and sigmoid colon. The patient was treated with ciprofloxacin and metronidazole. After one week, follow up sigmoidoscopy was performed owing to sustained fever and diarrhea. The lesions were aggravated and seemed webbed in appearance because of damage to the rectal mucosa. Abdominal computed tomography and rectal magnetic resonance imaging were performed, and showed a perianal and perirectal abscess. The patient underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage. Extended-spectrum beta-lactamase-producing K. pneumoniae was identified in pus culture. The antibiotics were switched to ertapenem. He improved after surgery and was discharged. K. pneumoniae can cause rapid invasive infection in patients with diabetes and a history of alcohol abuse. We report the first rare case of proctitis and perianal abscess caused by invasive K. pneumoniae infection.", "provenance": [ { "field": "n", "quote": "A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks." }, { "field": "population", "quote": "A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks." }, { "field": "intervention", "quote": "The patient was treated with ciprofloxacin and metronidazole." }, { "field": "intervention", "quote": "The patient underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage." }, { "field": "primaryOutcome", "quote": "showed a perianal and perirectal abscess" }, { "field": "result", "quote": "The lesions were aggravated and seemed webbed in appearance because of damage to the rectal mucosa." }, { "field": "result", "quote": "He improved after surgery and was discharged." } ] }, { "id": "pmid:25638864", "pmid": "25638864", "doi": null, "nctId": null, "pmcid": null, "title": "[Management of intestinal complications in inflammatory bowel diseases]", "firstAuthor": "Ribière", "multipleAuthors": true, "journal": "Rev Prat", "year": 2014, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with Crohn's disease who develop abdominal, pelvic or perianal abscesses", "intervention": "abscess drainage combined with antibiotics, and for perianal abscess drainage with non-tight setons plus antibiotics and anti-TNF therapy", "comparator": "surgery (resection)", "primaryOutcome": "need for surgery after abscess management", "result": "abscesses are drained and treated with antibiotics, but surgery is usually required if obstructive signs persist after the abscess resolves", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a narrative expert review summarizing management recommendations without original study data, a defined outcome measure, or sample size.", "directness": "indirect", "limitations": "No study design, methodology, or outcome data are reported; this is a general narrative review of IBD complication management rather than a study of anorectal abscess treatment in the general population.", "followUp": "", "plainFinding": "Drainage plus antibiotics, surgery if needed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25638864/", "sourceText": "The evolution of inflammatory bowel disease (IBD) is characterized by the occurrence of gastrointestinal complications. For Crohn's disease (CD), it is mainly strictures, fistulas and abdominal or pelvic abscess in luminal forms and perianal lesions (ulcers, fissures, fistula/abscess) in the perineal forms. For ulcerative colitis (UC), main complications are severe flare up and dysplasia/cancer. In Crohn's disease, stenosis can be treated medically in first line (steroid-immunosupppresseurs or antiTNF) especially when the inflammatory component is predominant or in extensive lesions. In case of limited lesions (< 4 cm) and low inflammatory component, endoscopic dilatation can be propose before surgery, especially in patients previously operated on. Abdomino-pelvic abscess should be drained if the size is greater than 4-5 cm and treated with antibiotics. If obstructive signs are present after the resolution of the abscess, surgery is usually required. In some cases, an antiTNF therapy can be discussed (ongoing trial with the GETAID). Surgery during the MC should be performed laparoscopically, particularly in uncomplicated forms (first ileocecal resection) but also whenever possible for complicated diseases. Anoperineal abscess must be drained by non-tight setons. Medical treatment also involves antibiotics and antiTNF, usually in combotherapy. Biological glue is especially interesting in simple fistulas. Collagen plugs have not demonstrated efficacy in simple or complex perianal Crohn's disease fistulas and may have a deleterious effect. They are therefore not recommended. Severe UC flare up are still conventionally treated with corticosteroids IV for 3-5 days, followed in case of failure of a 2nd line treatment with infliximab or ciclosporin. The place of emergency colectomy had regressed due to the effectiveness of medical treatments.", "provenance": [ { "field": "population", "quote": "For Crohn's disease (CD), it is mainly strictures, fistulas and abdominal or pelvic abscess in luminal forms and perianal lesions (ulcers, fissures, fistula/abscess) in the perineal forms." }, { "field": "intervention", "quote": "Abdomino-pelvic abscess should be drained if the size is greater than 4-5 cm and treated with antibiotics." }, { "field": "intervention", "quote": "Anoperineal abscess must be drained by non-tight setons." }, { "field": "intervention", "quote": "Medical treatment also involves antibiotics and antiTNF, usually in combotherapy." }, { "field": "comparator", "quote": "If obstructive signs are present after the resolution of the abscess, surgery is usually required." }, { "field": "result", "quote": "Abdomino-pelvic abscess should be drained if the size is greater than 4-5 cm and treated with antibiotics. If obstructive signs are present after the resolution of the abscess, surgery is usually required." }, { "field": "primaryOutcome", "quote": "If obstructive signs are present after the resolution of the abscess, surgery is usually required." } ] }, { "id": "pmid:25531359", "pmid": "25531359", "doi": "10.1159/000367835", "nctId": null, "pmcid": null, "title": "Role of immunosuppressives in special situations: perianal disease and postoperative period", "firstAuthor": "Ghosh", "multipleAuthors": true, "journal": "Dig Dis", "year": 2014, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with perianal Crohn's disease, including complex fistulising disease", "intervention": "immunosuppressants (azathioprine, anti-TNF, tacrolimus, thalidomide) with or without surgical drainage/seton", "comparator": "no treatment or conventional management", "primaryOutcome": "need for perianal surgery and disease recurrence", "result": "abscess drainage and seton placement were described as necessary before starting immunosuppressant or anti-TNF therapy", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a narrative review of Crohn's disease drug therapy, not a study testing whether abscesses can be managed without surgery, and it explicitly says drainage is needed first.", "directness": "indirect", "limitations": "abstract focuses on perianal Crohn's disease management with drugs, not on whether abscess drainage can be avoided; no original study design or patient numbers given for this specific question.", "followUp": "", "plainFinding": "Abscess drainage still needed first.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25531359/", "sourceText": "Complex perianal disease is associated with poor outcome and requires early effective therapy. Corticosteroids are not effective in perianal fistulising Crohn's disease, and antibiotics, immunosuppressants and anti-TNF therapy are required. It is important to consider combined medical surgical therapy after accurate imaging using an MRI scan of the pelvis. Drainage of any abscess at examination under anaesthesia and seton insertion are important before introduction of immunosuppressants and anti-TNF therapy. Long-term follow up of patients in a single centre reported responders to azathioprine having a reduced risk of perianal surgery (OR = 0.36; 95% CI: 0.27-0.46), but complex perianal fistulising Crohn's disease generally requires combination therapy with anti-TNF and azathioprine. Patients with recent perianal disease without fistulae and aged 40 years or older respond better to azathioprine monotherapy. Response to monotherapy with azathioprine is often slow and incomplete. In the recent GETAID study of early administration of azathioprine versus conventional management in patients at high risk of disabling disease, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery. In patients not responding to anti-TNF therapy, thalidomide or tacrolimus may be considered. Hyperbaric oxygen may be used as adjunctive therapy where available. The role of adipose-derived stem cell injection requires further long-term studies. In prevention of post-operative recurrence of Crohn's disease, azathioprine or 6-mercaptopurine had a favourable incremental cost-effectiveness ratio compared with no prophylactic therapy up to 1 year. In a Cochrane systematic review, azathioprine/6-mercaptopurine was associated with a significantly reduced risk of clinical recurrence [RR = 0.59, 95% CI: 0.38-0.92, number needed to treat (NNT) = 7] and severe endoscopic recurrence (RR = 0.6, 95% CI: 0.44-0.92, NNT = 4). Individual studies of prevention of post-operative recurrence using azathioprine/6-mercaptopurine have shown only modest benefit. In patients at high risk of relapse after surgical resection, anti-TNF therapy may be beneficial, but more data is required from ongoing studies. Strategies to prevent post-operative recurrence in Crohn's disease are evolving but need further refinement.", "provenance": [ { "field": "population", "quote": "Complex perianal disease is associated with poor outcome and requires early effective therapy." }, { "field": "intervention", "quote": "antibiotics, immunosuppressants and anti-TNF therapy are required" }, { "field": "comparator", "quote": "azathioprine/6-mercaptopurine was associated with a significantly reduced risk of clinical recurrence" }, { "field": "primaryOutcome", "quote": "a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery" }, { "field": "result", "quote": "Drainage of any abscess at examination under anaesthesia and seton insertion are important before introduction of immunosuppressants and anti-TNF therapy." } ] }, { "id": "pmid:25466213", "pmid": "25466213", "doi": "10.1186/s12879-014-0641-x", "nctId": null, "pmcid": "PMC4273458", "title": "Uncommon manifestations of Listeria monocytogenes infection", "firstAuthor": "Chavada", "multipleAuthors": true, "journal": "BMC Infect Dis", "year": 2014, "design": "case-series", "n": 3, "nField": "reported", "population": "Patients with unusual Listeria monocytogenes infections, including one with a perianal abscess", "intervention": "Antibiotics plus surgery", "comparator": "None", "primaryOutcome": "Clinical outcome after treatment", "result": "All three patients, including the one with perianal abscess, were treated with antibiotics and surgery with favourable outcomes", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a tiny case series of only three unrelated patients with different infections, not a controlled study of abscess treatment, so it cannot show whether surgery can be avoided.", "directness": "indirect", "limitations": "Only three cases reported, mixed infection types and sites, no comparison group, surgery was combined with antibiotics in all cases so their individual contributions cannot be separated.", "followUp": "", "plainFinding": "Abscess treated with surgery and antibiotics together.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25466213/", "sourceText": "BACKGROUND: Listeria monocytogenes causes gastroenteritis, meningitis and bacteraemia in immunocompromised, pregnant patients, the elderly as well in immunocompetent patients. Focal infections with this organism are uncommon, especially in sporadic (non-outbreak) setting, require high index of suspicion and are challenging to diagnose. We present 3 cases of Listeria monocytogenes presenting as focal infections to our hospitals, all of which are the first reported cases from Australia. CASE PRESENTATION: Three unrelated cases of unique focal infections caused by Listeria monocytogenes are presented. 1) A 73 year old Caucasian lady on immunosuppression for colorectal cancer presented with prosthetic knee joint septic arthritis, 2) An 83 year old Caucasian man presented with prosthetic vascular graft infection and 3) A 60 year old Asian man with perianal abscess. Except for case 1, the other cases had a prolonged duration of symptoms on presentation. Listeria was not thought to be causative organism in any of these cases until microbiological specimens isolated the organism. Matrix Associated Laser Desorption/Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) assisted in making an earlier diagnosis of the infection in all three cases. All of these patients had Listeria monocytogenes isolated from clinical specimens. They were managed with antibiotics and surgery with favourable outcomes. Public health investigations to determine any dietary association were done, however no intervention was thought to be necessary in any of the cases except provide dietary advice. The first two cases highlight the importance of microbiological sampling in serious infections for definitive antibiotic therapy to be administered. CONCLUSION: Sporadic focal infections with Listeria occur infrequently and are often not diagnosed till culture results from microbiological specimens become available. Dietary history should be an important aspect of thorough clinical history and food consumption advice is crucial in immunocompromised patients on similar lines as given to pregnant women about listeriosis.", "provenance": [ { "field": "n", "quote": "Three unrelated cases of unique focal infections caused by Listeria monocytogenes are presented." }, { "field": "population", "quote": "3) A 60 year old Asian man with perianal abscess." }, { "field": "intervention", "quote": "They were managed with antibiotics and surgery with favourable outcomes." }, { "field": "comparator", "quote": "They were managed with antibiotics and surgery with favourable outcomes." }, { "field": "primaryOutcome", "quote": "They were managed with antibiotics and surgery with favourable outcomes." }, { "field": "result", "quote": "They were managed with antibiotics and surgery with favourable outcomes." } ] }, { "id": "pmid:24571710", "pmid": "24571710", "doi": "10.1186/1752-1947-8-77", "nctId": null, "pmcid": "PMC4234930", "title": "Currarino syndrome in an adult presenting with a presacral abscess: a case report", "firstAuthor": "Shoji", "multipleAuthors": true, "journal": "J Med Case Rep", "year": 2014, "design": "case-series", "n": 1, "nField": "reported", "population": "32-year-old man with Currarino syndrome and a presacral abscess", "intervention": "abscess drainage through a perianal approach combined with antibiotics", "comparator": "no non-surgical comparator; later radical excision surgery", "primaryOutcome": "resolution of infection symptoms and abscess", "result": "symptoms disappeared after drainage and antibiotics, but excision surgery was still performed three months later", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this approach works in general", "directness": "indirect", "limitations": "single case report of a rare congenital condition (Currarino syndrome) rather than a typical anorectal abscess, with no comparison group", "followUp": "four years and six months after surgery", "plainFinding": "Drainage worked short-term; surgery followed later.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24571710/", "sourceText": "INTRODUCTION: Currarino syndrome (Currarino triad) was described in 1981 as a triad syndrome with a common embryogenesis in infants and with three characteristics: anorectal stenosis, a defect in the sacral bone, and a presacral mass. We describe here an unusual case of Currarino syndrome in an adult presenting with a presacral abscess but no meningitis. CASE PRESENTATION: A 32-year-old Japanese man presented with fever, arthralgia and buttock pain. A digital rectal examination showed mild rectal stenosis with local warmth and tenderness in the posterior wall of his rectum. Computed tomography showed a scimitar-shaped deformity of his sacrum and an 8cm presacral mass, which continued to a pedicle of his deformed sacrum. This was diagnosed as Currarino syndrome with a presacral abscess. The abscess was drained by a perianal approach with our patient treated with antibiotics. His symptoms soon disappeared. After three months, an excision was performed through a posterior sagittal approach. His postoperative course was uneventful and he was discharged 10 days after surgery. A histopathological examination revealed an infected epidermoid cyst. He has been free from recurrence as of four years and six months after surgery. CONCLUSIONS: We report a case of Currarino syndrome in an adult who presented with a presacral abscess but no meningitis. Abscess drainage followed by radical surgery resulted in a successful outcome.", "provenance": [ { "field": "population", "quote": "A 32-year-old Japanese man presented with fever, arthralgia and buttock pain." }, { "field": "intervention", "quote": "The abscess was drained by a perianal approach with our patient treated with antibiotics." }, { "field": "comparator", "quote": "After three months, an excision was performed through a posterior sagittal approach." }, { "field": "primaryOutcome", "quote": "His symptoms soon disappeared." }, { "field": "result", "quote": "Abscess drainage followed by radical surgery resulted in a successful outcome." }, { "field": "n", "quote": "A 32-year-old Japanese man presented with fever, arthralgia and buttock pain." } ] }, { "id": "pmid:24471302", "pmid": "24471302", "doi": null, "nctId": null, "pmcid": null, "title": "[Treatment of fistulizing Crohn's disease]", "firstAuthor": "Tonkić", "multipleAuthors": true, "journal": "Acta Med Croatica", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with Crohn's disease who have fistulas (abnormal tunnels) connecting the bowel to other organs or skin, including perianal fistulas and abscesses", "intervention": "antibiotics, immunosuppressants, anti-TNF drugs, seton placement, and surgical drainage for perianal disease", "comparator": "different treatment approaches compared to each other depending on fistula type and severity", "primaryOutcome": "whether fistulas and abscesses heal or resolve with different treatment approaches", "result": "the abstract states that if a perianal abscess is present it should be drained urgently, and complex perianal disease needs combined drug and surgical treatment", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is an expert narrative review summarizing treatment recommendations, not a study with original data comparing surgical versus non-surgical abscess treatment", "directness": "indirect", "limitations": "the abstract is a general review of Crohn's fistula treatment, not a study specifically testing whether abscesses can be treated without surgery, and no controlled trials are described for this question", "followUp": "", "plainFinding": "Abscess drainage recommended, not avoided.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24471302/", "sourceText": "The treatment of fistulating Crohn's disease should include a combined medical and surgical approach and should be defined on an individual basis. Asymptomatic enteroenteric fistulas usually require no treatment, but internal fistulas (gastrocolic, duodenocolic, enterovesical) that cause severe or persistent symptoms require surgical intervention. While low asymptomatic anal-introital fistula may not need surgical treatment, in case of a symptomatic enterovaginal fistula surgery is usually required. There are no controlled-randomized trials to assess the effect of medical treatment for non-perianal fistulating Crohn's disease. The incidence of perianal fistulae varies according to the location of the disease, with its occurrence varying between 21-23%. The diagnostic approach should include an examination under anesthesia, endoscopy, and either MRI or EUS before the treatment begins. Asymptomatic simple perianal fistulas require no treatment. The presence of a perianal abscess should be ascertained and if present should be drained urgently. In case of a complex perianal disease, seton placement should also be recommended. Antibiotics (metronidazole and ciprofloxacine) are useful for treating complex perianal disease, however, when discontinued, most of the fistulas relapse. The current consensus suggests that azathioprine/6-mercaptopurine is the first line medical therapy for complex perianal disease, which is always given in combination with surgical therapy (seton, fistulotomy/fistulectomy). Anti TNF-alpha agents (infliximab and adalimumab) should be used as a second choice medical treatment. In refractory and extensive complex perianal disease a diverting stoma or proctectomy should be performed.", "provenance": [ { "field": "population", "quote": "The treatment of fistulating Crohn's disease should include a combined medical and surgical approach" }, { "field": "intervention", "quote": "Antibiotics (metronidazole and ciprofloxacine) are useful for treating complex perianal disease" }, { "field": "intervention", "quote": "azathioprine/6-mercaptopurine is the first line medical therapy for complex perianal disease, which is always given in combination with surgical therapy (seton, fistulotomy/fistulectomy)" }, { "field": "intervention", "quote": "Anti TNF-alpha agents (infliximab and adalimumab) should be used as a second choice medical treatment" }, { "field": "comparator", "quote": "In refractory and extensive complex perianal disease a diverting stoma or proctectomy should be performed" }, { "field": "result", "quote": "The presence of a perianal abscess should be ascertained and if present should be drained urgently" }, { "field": "result", "quote": "In case of a complex perianal disease, seton placement should also be recommended" }, { "field": "primaryOutcome", "quote": "There are no controlled-randomized trials to assess the effect of medical treatment for non-perianal fistulating Crohn's disease" } ] }, { "id": "pmid:23771984", "pmid": "23771984", "doi": "10.1093/cid/cit392", "nctId": null, "pmcid": null, "title": "Extraintestinal Clostridium difficile infections", "firstAuthor": "Mattila", "multipleAuthors": true, "journal": "Clin Infect Dis", "year": 2013, "design": "retrospective", "n": 31, "nField": "reported", "population": "patients with extraintestinal Clostridium difficile infections, including some with perianal abscesses", "intervention": "none - this study did not test a treatment, it characterized infections", "comparator": "", "primaryOutcome": "clinical features and risk factors of extraintestinal C. difficile infections", "result": "mortality and disease severity were linked to patients' underlying illnesses, not to any treatment comparison", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a small retrospective chart review with no treatment comparison, so it cannot show whether surgery or non-surgical treatment works better for abscesses", "directness": "indirect", "limitations": "retrospective record review, very small subgroup with perianal abscess, no comparison of treatments, mostly focused on bacteriology and mortality rather than abscess management", "followUp": "1-year", "plainFinding": "Does not address abscess treatment choice.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23771984/", "sourceText": "BACKGROUND: Clostridium difficile causes diarrhea that ranges from a benign, self-limiting antibiotic use-associated disease to a life-threatening pseudomembranous colitis. Clostridium difficile has rarely been isolated in extraintestinal infections. Our objective was to characterize clinical features and risk factors of these infections. METHODS Extraintestinal C. difficile infections (CDIs) were searched for in an electronic database of all C. difficile-positive isolates found during a 10-year period. The medical records were reviewed retrospectively. Disease severity and comorbidities of the patients were evaluated using Horn disease severity and Charlson comorbidity indexes. RESULTS: Extraintestinal CDI was found in 31 patients who comprised 0.17% of all CDIs. Two patients had bacteremic infections, 4 had abdominal infections without any prior surgery, 7 had abdominal infections after surgery, 4 had perianal abscesses, 13 had wound infections, and 1 had C. difficile in a urinary catheter. In most cases (85%), C. difficile was isolated together with other microbes. Most (81%) patients developed the infection when hospitalized and many had severe comorbidities. Sixteen (52%) had diarrhea. The 1-year mortality rate was 36% and it correlated with the severity of underlying diseases. CONCLUSIONS: Extraintestinal CDIs occur mainly in hospitalized patients with significant comorbidities. Extraintestinal CDIs in the abdominal area may result from either intestinal perforation after infection or after intestinal surgery. Wound infections may result from colonization by feces. Clostridium difficile may reach distant sites via bacteremia. Mortality in extraintestinal CDIs is associated with the severity of underlying diseases.", "provenance": [ { "field": "n", "quote": "Extraintestinal CDI was found in 31 patients" }, { "field": "population", "quote": "4 had perianal abscesses" }, { "field": "intervention", "quote": "Our objective was to characterize clinical features and risk factors of these infections." }, { "field": "primaryOutcome", "quote": "to characterize clinical features and risk factors of these infections" }, { "field": "result", "quote": "The 1-year mortality rate was 36% and it correlated with the severity of underlying diseases." }, { "field": "followUp", "quote": "The 1-year mortality rate was 36%" } ] }, { "id": "pmid:23577135", "pmid": "23577135", "doi": "10.1371/journal.pone.0060624", "nctId": null, "pmcid": "PMC3618431", "title": "Clinical and microbiological characteristics of perianal infections in adult patients with acute leukemia", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "PLoS One", "year": 2013, "design": "retrospective", "n": 74, "nField": "reported", "population": "adult patients with acute leukemia who developed perianal infection", "intervention": "surgical treatment of the perianal infection/anal fistula", "comparator": "non-surgical (medical) management of the perianal infection", "primaryOutcome": "recurrence of perianal infection", "result": "patients who had surgery tended to have fewer recurrences, but this was not statistically significant", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a single-center retrospective review with a small subgroup comparison that just missed statistical significance, so it can't reliably show whether surgery helps.", "directness": "indirect", "limitations": "retrospective design, single center, surgical vs non-surgical comparison was not significant (p=0.067), and patients are immunocompromised leukemia patients rather than the general population with anorectal abscess", "followUp": "", "plainFinding": "Surgery trend fewer recurrences, not significant", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23577135/", "sourceText": "BACKGROUND: Perianal infection is a common problem for patients with acute leukemia. However, neutropenia and bleeding tendency are relatively contraindicated to surgical intervention. The epidemiology, microbiology, clinical manifestations and outcomes of perianal infection in leukemic patients are also rarely discussed. METHOD: The medical records of 1102 adult patients with acute leukemia at a tertiary medical center in Taiwan between 2001 and 2010 were retrospectively reviewed and analyzed. RESULT: The prevalence of perianal infection was 6.7% (74 of 1102) in adult patients with acute leukemia. Twenty-three (31%) of the 74 patients had recurrent episodes of perianal infections. Patients with acute myeloid leukemia had higher recurrent rates than acute lymphoblastic leukemia patients (p = 0.028). More than half (n = 61, 53%) of the perianal infections were caused by gram-negative bacilli, followed by gram-positive cocci (n = 36, 31%), anaerobes (n = 18, 15%) and Candida (n = 1, 1%) from pus culture. Eighteen patients experienced bacteremia (n = 24) or candidemia (n = 1). Overall 41 (68%) of 60 patients had polymicrobial infection. Escherichia coli (25%) was the most common micro-organism isolated, followed by Enterococcus species (22%), Klebsiella pneumoniae (13%), and Bacteroides species (11%). Twenty-five (34%) of 74 patients received surgical intervention. Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067). Four (5%) patients died within 30 days after diagnosis of perianal infection. Univariate analysis of 30-day survival revealed the elderly (≧ 65 years) (p = 0.015) and patients with shock (p<0.001) had worse outcome. Multivariate analysis showed septic shock to be the independent predictive factor of 30-day crude mortality of perianal infections (p = 0.016). CONCLUSION: Perianal infections were common and had high recurrence rate in adult patients with acute leukemia. Empirical broad-spectrum antibiotics with anaerobic coverage should be considered. Shock independently predicted 30-day crude mortality. Surgical intervention for perianal infection remains challenging in patients with acute leukemia.", "provenance": [ { "field": "n", "quote": "Twenty-five (34%) of 74 patients received surgical intervention." }, { "field": "population", "quote": "The prevalence of perianal infection was 6.7% (74 of 1102) in adult patients with acute leukemia." }, { "field": "intervention", "quote": "Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067)." }, { "field": "comparator", "quote": "neutropenia and bleeding tendency are relatively contraindicated to surgical intervention" }, { "field": "primaryOutcome", "quote": "Twenty-three (31%) of the 74 patients had recurrent episodes of perianal infections." }, { "field": "result", "quote": "Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067)." } ] }, { "id": "pmid:28839719", "pmid": "28839719", "doi": "10.1136/flgastro-2012-100160", "nctId": null, "pmcid": "PMC5369793", "title": "A multidisciplinary team model of caring for patients with perianal Crohn's disease incorporating a literature review, topical therapy and personal practice", "firstAuthor": "Garrick", "multipleAuthors": true, "journal": "Frontline Gastroenterol", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with perianal Crohn's disease", "intervention": "antibiotic therapy, immunosuppression, immunomodulation and topical wound management (honey and silver dressings)", "comparator": "surgery alone versus combined medical and surgical treatment", "primaryOutcome": "overall management and disease outcomes in perianal Crohn's disease, not a single defined outcome", "result": "a combination of medical and surgical treatment, including topical wound care, is suggested to give the best outcomes", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a narrative literature review and personal practice summary, not a controlled study testing abscess treatment without surgery.", "directness": "indirect", "limitations": "abstract does not describe a specific study design, patient numbers, or controlled comparison; it is an expert review and recommendation piece.", "followUp": "", "plainFinding": "Combined therapy, not surgery alone, works best.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28839719/", "sourceText": "BACKGROUND: Crohn's disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist. METHODS: This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images. RESULTS: Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management-in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles. CONCLUSIONS: Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.", "provenance": [ { "field": "population", "quote": "Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation." }, { "field": "intervention", "quote": "Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery." }, { "field": "comparator", "quote": "The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes." }, { "field": "primaryOutcome", "quote": "This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT)" }, { "field": "result", "quote": "A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes." } ] }, { "id": "pmid:23396392", "pmid": "23396392", "doi": "10.1016/j.ijscr.2012.08.005", "nctId": null, "pmcid": "PMC3604705", "title": "Beware the ischiorectal abscess", "firstAuthor": "Hogan", "multipleAuthors": true, "journal": "Int J Surg Case Rep", "year": 2013, "design": "case-series", "n": 1, "nField": "reported", "population": "65-year-old man with an ischiorectal (anorectal) abscess that had formed a connection to the spinal canal", "intervention": "non-surgical management with antibiotics after the patient refused definitive surgery", "comparator": "standard surgical treatment of the abscess", "primaryOutcome": "resolution of infection and clinical improvement", "result": "the abscess eventually drained spontaneously through the skin and the patient's sepsis improved, but conservative management of this condition is linked to up to 30% mortality", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single unusual case report with no comparison group, so it can't show whether avoiding surgery is generally safe or effective.", "directness": "indirect", "limitations": "single case, highly atypical abscess connected to a spinal defect, patient refused surgery by choice rather than by medical trial, no control group", "followUp": "", "plainFinding": "Improved without surgery, but risky.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23396392/", "sourceText": "INTRODUCTION: Ischiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare. PRESENTATION OF CASE: A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically. DISCUSSION: Few general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention. CONCLUSION: This case highlights challenges encountered in the management of complicated ASM in a general hospital.", "provenance": [ { "field": "n", "quote": "A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches." }, { "field": "population", "quote": "A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches." }, { "field": "intervention", "quote": "He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought." }, { "field": "intervention", "quote": "The patient in this case was adamant that he did not consent to definitive surgical intervention." }, { "field": "comparator", "quote": "In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously." }, { "field": "result", "quote": "He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically." }, { "field": "result", "quote": "Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis)." }, { "field": "primaryOutcome", "quote": "He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically." } ] }, { "id": "pmid:21975159", "pmid": "21975159", "doi": null, "nctId": null, "pmcid": null, "title": "Diagnosis and treatment of fistulising Crohn's disease", "firstAuthor": "Hvas", "multipleAuthors": true, "journal": "Dan Med Bull", "year": 2011, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with Crohn's disease who develop fistulas (abnormal connections between the bowel and other organs or skin)", "intervention": "various treatments for Crohn's-related fistulas and abscesses, including drainage, antibiotics, immune-suppressing drugs, and surgery", "comparator": "different treatment approaches compared to each other within the review", "primaryOutcome": "closure of fistulas and absence of abscesses", "result": "the review states that any abscess should be drained, and that fistula treatments vary from antibiotics and medication to surgery depending on complexity", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general review article about Crohn's disease fistulas, not a study designed to test whether abscesses can be treated without surgery, and it does not report original data or a specific comparison for abscess treatment alone.", "directness": "indirect", "limitations": "This abstract is about fistula treatment in Crohn's disease patients specifically, not about anorectal abscess treatment in general; it is a narrative review without original patient data on abscess management alone.", "followUp": "", "plainFinding": "Abscesses should be drained, per review.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21975159/", "sourceText": "A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations. Most are perianal fistulas, and these may be classified as simple or complex. The initial investigation of perianal fistulas includes imaging (MRI of the pelvis and rectum), examination under anaesthesia (EUA) with digital imaging, endoscopy, probing and anal ultrasound. Non-perianal fistulas require contrast imaging and/or CT/MRI for complete anatomical definition. Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated. Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction. MR imaging is required to demonstrate definitive fistula closure. Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy. In cases with persistent secretion, infliximab at 5 mg/kg is given at weeks 0, 2, and 6 and subsequently every 8 weeks. Adalimumab may improve fistula response in both infliximab-naïve patients and following infliximab treatment failure. Local therapy with fibrin glue or fistula plugs is rarely effective. Definitive surgical closure of perianal fistulas using an advancement flap may be attempted, but this procedure is associated with a high risk of relapse. Colostomy and proctectomy are the ultimate surgical treatment options for fistulas. Intestinal resection is almost always needed for the closure of symptomatic non-perianal fistulas.", "provenance": [ { "field": "population", "quote": "Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations." }, { "field": "intervention", "quote": "Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated." }, { "field": "result", "quote": "Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated." }, { "field": "primaryOutcome", "quote": "Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction." }, { "field": "comparator", "quote": "Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy." } ] }, { "id": "pmid:21785979", "pmid": "21785979", "doi": "10.1007/s00383-011-2956-7", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome", "firstAuthor": "Afşarlar", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2011, "design": "retrospective", "n": 158, "nField": "reported", "population": "children with perianal abscess and fistula-in-ano, median age 7.2 months", "intervention": "incision and drainage of the abscess, with or without antibiotics", "comparator": "spontaneous drainage with local wound care, with or without antibiotics", "primaryOutcome": "recurrence of abscess and development of fistula-in-ano", "result": "no significant difference in recurrence or fistula formation between incision/drainage and spontaneous drainage groups, but antibiotics reduced fistula formation", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a retrospective chart review without randomization, so differences between treatment groups could be due to other factors rather than the treatment itself.", "directness": "direct", "limitations": "Retrospective design, not randomized, and follow-up period was relatively short and variable (mean 10.6 ± 8.6 months).", "followUp": "10.6 ± 8.6 months", "plainFinding": "No difference: surgery vs. no surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21785979/", "sourceText": "PURPOSE: The aims of this study are to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in children, and to assess our experience in treatment, and to identify factors that affected the clinical outcomes. METHODS: A retrospective review of children with perianal abscess and fistula-in-ano was carried out in a tertiary care children's hospital from January 2005 to December 2010. Demographic information of the patients, localization of the lesions, treatment procedures, microbial organisms in pus, usage of antibiotics, abscess recurrence, development of fistula-in-ano, and duration of symptoms were recorded. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study. RESULTS: A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study. Initial examination of the 136 patients revealed perianal abscess and 22 patients with fistula-in-ano. Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%), and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy. Patients were divided into two groups according to age distribution, 98 of the patients were younger than 12 months, and 60 were older than 12 months of age. There was no significant difference in sex distribution, localization of the lesions, treatment procedures, recurrence of abscess and fistula-in-ano formation between the two age groups (p > 0.05). Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups. Kind of the microorganisms in pus swaps did not effect the fistula-in-ano formation. Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001), but did not effect the recurrence of perianal abscess (p > 0.05). The mean follow-up period was 10.6 ± 8.6 months. While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy). CONCLUSIONS: Although management of perianal abscess is still controversial, simple drainage of the perianal abscess with additional antibiotic therapy reduces the development of fistula-in-ano. Fistula-in-ano within children has a chance of spontaneous resolution thus the immediate surgical intervention should be avoided.", "provenance": [ { "field": "n", "quote": "A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study." }, { "field": "population", "quote": "A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study." }, { "field": "intervention", "quote": "Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%)" }, { "field": "comparator", "quote": "and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy." }, { "field": "primaryOutcome", "quote": "Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups." }, { "field": "result", "quote": "Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups." }, { "field": "followUp", "quote": "The mean follow-up period was 10.6 ± 8.6 months." } ] }, { "id": "pmid:21575105", "pmid": "21575105", "doi": "10.1111/j.1442-200X.2011.03395.x", "nctId": null, "pmcid": null, "title": "Management of perianal abscess with hainosankyuto in neonates and young infants", "firstAuthor": "Kawahara", "multipleAuthors": true, "journal": "Pediatr Int", "year": 2011, "design": "case-series", "n": 15, "nField": "reported", "population": "male infants under 3 months old with perianal abscess", "intervention": "oral traditional Japanese herbal medicine (hainosankyuto, TJ-122)", "comparator": "none (no surgery or antibiotics used)", "primaryOutcome": "cure of perianal abscess without recurrence", "result": "14 of 15 infants were cured without recurrence, most within 28-60 days", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a small, uncontrolled case series without a comparison group, so it cannot reliably prove the treatment works better than surgery or no treatment.", "directness": "direct", "limitations": "no control group, small sample size, all male infants, no comparison to surgical treatment or placebo", "followUp": "median 28 days (range, 14-117 days)", "plainFinding": "Herbal medicine cured most infants.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21575105/", "sourceText": "BACKGROUND: Perianal abscess (PA) is a common condition acquired in infancy, yet its treatment method remains controversial. We reviewed the outcome of neonates and young infants with PA who were treated with the traditional Japanese medicine, hainosankyuto (TJ-122). METHODS: Fifteen male infants with PA under the age of 3 months were reviewed. The median age of infants at disease onset was 33 days (range, 18-88 days) and the median bodyweight was 4.1 kg (range, 2.5-6.4 kg). TJ-122 was administered at a dose of 0.20 g/kg/day (n= 13) or 0.25 g/kg/day (n= 2) orally in two or three divided doses before meals. Antibiotics were not used in any of the patients. RESULTS: Of the 15 patients, 14 were cured and had no recurrence, with a median TJ-122 administration of 28 days (range, 14-117 days). Eight patients were cured within 28 days (53%) and 12 were cured within 60 days (80%). One patient, who was later diagnosed with growth hormone deficiency, showed incomplete healing of PA with intermittent pus discharge and recurrence. The patient was cured by 1 year of age following repeated administration of TJ-122 and juzentaihoto (TJ-48). CONCLUSION: Medical management with TJ-122 was effective in most neonates and young infants with PA. It appears prudent to manage these patients with hainosankyuto before resorting to surgical intervention.", "provenance": [ { "field": "population", "quote": "Fifteen male infants with PA under the age of 3 months were reviewed." }, { "field": "intervention", "quote": "TJ-122 was administered at a dose of 0.20 g/kg/day (n= 13) or 0.25 g/kg/day (n= 2) orally in two or three divided doses before meals." }, { "field": "comparator", "quote": "Antibiotics were not used in any of the patients." }, { "field": "primaryOutcome", "quote": "Of the 15 patients, 14 were cured and had no recurrence" }, { "field": "result", "quote": "Of the 15 patients, 14 were cured and had no recurrence, with a median TJ-122 administration of 28 days (range, 14-117 days). Eight patients were cured within 28 days (53%) and 12 were cured within 60 days (80%)." }, { "field": "n", "quote": "Fifteen male infants with PA under the age of 3 months were reviewed." } ] }, { "id": "pmid:21066991", "pmid": "21066991", "doi": "10.2298/aci1003089g", "nctId": null, "pmcid": null, "title": "The role of pelvic MRI in assesment of combined surgical and infliximab treatment for perianal Crohn's disease", "firstAuthor": "Gligorijević", "multipleAuthors": true, "journal": "Acta Chir Iugosl", "year": 2010, "design": "prospective-cohort", "n": 24, "nField": "reported", "population": "patients with perianal Crohn's disease", "intervention": "combined surgical treatment (seton placement) plus infliximab infusions, with MRI assessment", "comparator": "before versus after infliximab treatment (no separate control group)", "primaryOutcome": "fistula activity score (PDAI) and MRI-assessed remission of fistula/abscess", "result": "PDAI score dropped significantly after infliximab, with 46% complete response and MRI showing remission in most re-scanned patients", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small uncontrolled group with no comparison arm, so it's hard to know how much benefit came from surgery versus the drug.", "directness": "indirect", "limitations": "No control group, small sample size, and treatment combined surgery (seton) with infliximab rather than testing non-surgical treatment alone.", "followUp": "8 weeks", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21066991/", "sourceText": "AIM: To evaluate the role of pelvic MRI in diagnosis and assesment of combined surgical and infliximab treatment of perianal Crohn's disease (PACD). METHOD: 24 patients with signs of PACD were prospectively evaluated. They were previously treated with azathyoprin for a period of 6 months to 7 years and antibiotics and than started on Infliximab 5 mg/kg (IFX) at 0, 2 and 6 weeks induction protocol. Luminal CD activity was assesed by colonoscopy. Perianal Disease Activity Index (PDAI) was calculated to evaluate perianal fistulae activity. Surgical examination under anesthesia (EUA) was performed and non-cutting seton placed where appropriate. Pelvic MRI was performed in each patient before Infliximab treatment, and in half of the patients after IFX. MRI criteria were used to asses activity and remission of PACD. RESULTS: 14/24 (58.5%) patients had ileocolitis, 10/24 (41.5%) colitis, and in 22/24 (91.7%) rectum was affected. Median disease duration was 5.5 +/- 2.5 years. MRI revealed simple fistula in 4/24 (16.7%) and complex fistula in 20/24 (83.3%) patients. Abscess was present in 19/24 (79%) patients. Enterocutaneous and recto-vaginal fistula was found in 2 (8.3%) and 3 (12.5%) patients, respectively. Median PDAI before and 8 weeks after IFX treatment was 8.3 +/- 2.08 and 3.5 +/- 1.03, respectively (p = 0.00064). Incomplete response (reduction fistulae drainage by 50%) was found in 10/24 (42%) patients, complete response (no drainage) in 11/24 (46%) patients, while in 3/24 (12.5%) new fistula opened. Control pelvic MRI was performed in 13/24 (54%) patients. Of those, 9/13 (69%) had complete remission according to MRI criteria. Seton was removed after second IFX dose in 15/24 (62.5%) patients and placed again in 2/24 (8%) patients 4 months after completion of IFX treatment. CONCLUSION: In patients with PACD, pelvic MRI before and after IFX treatment is an important diagnostic tool to asses fistula tract localisation, reveal abscess, planning adequate treatment approach and assess the effect of treatment. Surgical decision to remove seton was in accordance with MRI criteria for remission in PACD.", "provenance": [ { "field": "n", "quote": "24 patients with signs of PACD were prospectively evaluated" }, { "field": "population", "quote": "24 patients with signs of PACD were prospectively evaluated" }, { "field": "intervention", "quote": "started on Infliximab 5 mg/kg (IFX) at 0, 2 and 6 weeks induction protocol" }, { "field": "intervention", "quote": "Surgical examination under anesthesia (EUA) was performed and non-cutting seton placed where appropriate" }, { "field": "comparator", "quote": "Pelvic MRI was performed in each patient before Infliximab treatment, and in half of the patients after IFX" }, { "field": "primaryOutcome", "quote": "Perianal Disease Activity Index (PDAI) was calculated to evaluate perianal fistulae activity" }, { "field": "result", "quote": "Median PDAI before and 8 weeks after IFX treatment was 8.3 +/- 2.08 and 3.5 +/- 1.03, respectively (p = 0.00064)" }, { "field": "result", "quote": "complete response (no drainage) in 11/24 (46%) patients" } ] }, { "id": "pmid:20835504", "pmid": "20835504", "doi": null, "nctId": null, "pmcid": null, "title": "The evaluation of bacteriology in perianal abscesses of 81 adult patients", "firstAuthor": "Ulug", "multipleAuthors": true, "journal": "Braz J Infect Dis", "year": 2010, "design": "case-series", "n": 81, "nField": "reported", "population": "adult patients with perianal abscesses", "intervention": "not applicable (microbiological analysis of abscess specimens)", "comparator": "not applicable, no treatment comparison made", "primaryOutcome": "types of bacteria causing the abscesses", "result": "aerobic bacteria (not anaerobic) were the most common organisms found", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a small, non-comparative case series that only looked at bacteria types and did not test or compare surgical versus non-surgical treatment.", "directness": "indirect", "limitations": "No comparison of treatment approaches (surgery vs no surgery) was made; study only describes bacteriology, all patients presumably underwent drainage as standard care.", "followUp": "", "plainFinding": "Identified common bacteria, not treatment effectiveness.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20835504/", "sourceText": "OBJECTIVE: Treatment of perianal abscesses requires prompt surgical drainage and antimicrobial therapy. However, we should encourage the selective use of antimicrobial agents on a case-by-case basis, especially because there is no evidence that uncomplicated perianal abscesses can be safely treated only with drainage. For this reason, it is important to identify the causative organisms; therefore, we accessed the microbiological analysis of these patients. PATIENTS AND METHODS: In this study, 81 consecutive adult patients with perianal abscesses, who presented at a university hospital in Diyarbakir from January 2004 to December 2006, were included. Clinical and laboratory data, and results of microbiological analysis were recorded. RESULTS: All specimens, except seven, yielded bacterial growth. Escherichia coli, Bacteriodes spp., coagulase-negative Staphylococci, and Staphylococcus aureus were the most common isolated organisms. CONCLUSION: In contrast to other investigators, this study demonstrated that aerobic organisms are the predominant isolates in these infections.", "provenance": [ { "field": "n", "quote": "81 consecutive adult patients with perianal abscesses" }, { "field": "population", "quote": "81 consecutive adult patients with perianal abscesses, who presented at a university hospital in Diyarbakir" }, { "field": "primaryOutcome", "quote": "it is important to identify the causative organisms; therefore, we accessed the microbiological analysis of these patients" }, { "field": "result", "quote": "this study demonstrated that aerobic organisms are the predominant isolates in these infections" }, { "field": "intervention", "quote": "Treatment of perianal abscesses requires prompt surgical drainage and antimicrobial therapy" }, { "field": "comparator", "quote": "there is no evidence that uncomplicated perianal abscesses can be safely treated only with drainage" } ] }, { "id": "pmid:20109634", "pmid": "20109634", "doi": "10.1016/j.suc.2009.09.004", "nctId": null, "pmcid": null, "title": "Anorectal Crohn's disease", "firstAuthor": "Lewis", "multipleAuthors": true, "journal": "Surg Clin North Am", "year": 2010, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with Crohn's disease affecting the anus or rectum", "intervention": "combined medical and surgical treatment (draining abscess, setons, antibiotics, immunosuppressive drugs like infliximab)", "comparator": "", "primaryOutcome": "successful treatment of perianal fistula/abscess disease", "result": "abstract states abscesses should be drained surgically alongside medical therapy; does not report outcomes of avoiding surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general review of treatment approach, not a study with measured outcomes comparing surgery versus no surgery for abscess.", "directness": "indirect", "limitations": "abstract is a narrative review describing general treatment strategy, not an original study with data on abscess drainage versus non-surgical treatment.", "followUp": "", "plainFinding": "Review says abscesses need draining, not avoidance.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20109634/", "sourceText": "Crohn's disease manifests with perianal or rectal symptoms in approximately one-third of patients, and is associated with a more aggressive natural history. Due to the chronic relapsing nature of the disease, surgery has been traditionally avoided. However, combined medical and surgical intervention when treating perianal fistulae has been shown to offer the best chance for success. Endoanal ultrasound examination or pelvic magnetic resonance imaging should be done in conjunction with an examination under anesthesia to characterize the disease. Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae. Antibiotics and immunosuppressive therapy (especially with infliximab) should also be initiated. Simple fistulae can be treated surgically by fistulotomy or anal fistula plug. Complex fistulae can be closed with either an anal fistula plug or covered with flaps. Up to 20% of patients anorectal Crohn's disease require proctectomy for persistent and disabling disease.", "provenance": [ { "field": "population", "quote": "Crohn's disease manifests with perianal or rectal symptoms in approximately one-third of patients" }, { "field": "intervention", "quote": "Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae. Antibiotics and immunosuppressive therapy (especially with infliximab) should also be initiated." }, { "field": "result", "quote": "Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae." }, { "field": "primaryOutcome", "quote": "combined medical and surgical intervention when treating perianal fistulae has been shown to offer the best chance for success" } ] }, { "id": "pmid:20105258", "pmid": "20105258", "doi": "10.1111/j.1440-1754.2009.01644.x", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in children: aetiology, management and outcome", "firstAuthor": "Ezer", "multipleAuthors": true, "journal": "J Paediatr Child Health", "year": 2010, "design": "case-series", "n": 39, "nField": "reported", "population": "children with perianal abscess and/or fistula-in-ano", "intervention": "incision and drainage with antibiotics, or antibiotics alone (non-surgical) for perianal abscess", "comparator": "surgical treatment (fistulotomy or fistulectomy) for the resulting fistula", "primaryOutcome": "development of fistula-in-ano after treatment of perianal abscess", "result": "85% of abscess patients went on to develop a fistula regardless of initial treatment, only 15% healed without fistula", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "small retrospective case series without a control group, so it can't reliably show whether avoiding surgery works.", "directness": "direct", "limitations": "retrospective design, no comparison group, some patients lost to follow-up", "followUp": "", "plainFinding": "High fistula rate despite treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20105258/", "sourceText": "AIM: We aimed to assess our experience in treatment and outcome of perianal abscess and/or fistula-in-ano in children. METHOD: The patients who were treated for perianal abscess and/or fistula-in-ano from January 2000 to December 2005 were included. Age, sex, duration of symptoms, number and site of the perianal abscess and/or fistula-in-ano, treatment modality and recurrences were recorded. RESULTS: The study consisted of 39 patients (36 boys) with a mean age of 29 +/- 49.1 months. At first examination the diagnosis was perianal abscess in 20 patients, perianal abscess with fistula in five patients and fistula-in-ano in 14 patients. No patients had an underlying illness. The primary local treatment of perianal abscess with or without fistula was incision and drainage (with or without antibiotic therapy) in 21 patients, and local care with antibiotic therapy was given to four patients. Of 20 patients with perianal abscess, 17 developed fistula-in-ano and three healed. One patient in the perianal abscess group who developed fistula-in-ano and two patients in the fistula group were lost to follow-up. Thirty-three patients with fistula-in-ano underwent surgical treatment either through a fistulotomy or through a fistulectomy. Five (15.1%) patients who experienced recurrent fistula-in-ano underwent fistulotomy were completely cured after the second operation. CONCLUSION: Treatment of a perianal abscess either through incision and drainage with antibiotics or through antibiotics alone resulted in a high rate (85%) of fistula formation. Fistula-in-ano can be treated either by fistulotomy or by fistulectomy, both of which are associated with a reasonable chance of recurrence of fistula-in-ano formation. We obtained good results in our patients through surgical approach (fistulotomy or fistulectomy), for fistula-in-ano formed following treatment of perianal abscess.", "provenance": [ { "field": "n", "quote": "The study consisted of 39 patients (36 boys)" }, { "field": "population", "quote": "perianal abscess and/or fistula-in-ano in children" }, { "field": "intervention", "quote": "local care with antibiotic therapy was given to four patients" }, { "field": "intervention", "quote": "The primary local treatment of perianal abscess with or without fistula was incision and drainage (with or without antibiotic therapy) in 21 patients" }, { "field": "comparator", "quote": "Thirty-three patients with fistula-in-ano underwent surgical treatment either through a fistulotomy or through a fistulectomy." }, { "field": "primaryOutcome", "quote": "Of 20 patients with perianal abscess, 17 developed fistula-in-ano and three healed." }, { "field": "result", "quote": "Treatment of a perianal abscess either through incision and drainage with antibiotics or through antibiotics alone resulted in a high rate (85%) of fistula formation." } ] }, { "id": "pmid:20005498", "pmid": "20005498", "doi": "10.1016/j.jsurg.2009.07.013", "nctId": null, "pmcid": null, "title": "Perirectal abscess infections related to MRSA: a prevalent and underrecognized pathogen", "firstAuthor": "Brown", "multipleAuthors": true, "journal": "J Surg Educ", "year": 2009, "design": "retrospective", "n": 124, "nField": "reported", "population": "adults with a perirectal (anorectal) abscess", "intervention": "antibiotics given together with incision and drainage", "comparator": "incision and drainage without matched antibiotic coverage / cases where antibiotics were not adequate for the organism", "primaryOutcome": "how common MRSA was in the abscess cultures and whether prescribed antibiotics actually covered the bacteria found", "result": "MRSA was found in 19% of cases, and when it was present, antibiotics only adequately covered it 33% of the time", "resultDirection": "unclear", "quality": "low", "qualityWhy": "it is a retrospective chart review over 8 years with no comparison of surgical versus non-surgical outcomes, so it can't show whether abscesses can be treated without surgery.", "directness": "indirect", "limitations": "Retrospective design, cultures were only taken in 52% of patients, no randomization, and no direct comparison of surgery versus no surgery as treatment.", "followUp": "", "plainFinding": "MRSA common, antibiotics often inadequate.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20005498/", "sourceText": "BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is not a commonly recognized pathogen isolated from perirectal abscesses. Complex perirectal abscesses of MRSA origin may present a significant challenge to the physician and result in treatment failure. The aim of our study was to determine the prevalence of MRSA in our patient population with perirectal abscesses and whether antibiotics coverage, if given, was adequate. METHODS: We conducted a retrospective study of all adult patients who presented with a perirectal abscess. The bacteriology of the cultures taken from more than 100 patients during an 8-year period was examined. The prevalence of MRSA was specifically analyzed, and the sensitivities of the organisms isolated were then compared with any antibiotics prescribed to determine the adequacy of coverage. RESULTS: In all, 124 patients were treated for perirectal abscess during the 8-year period. Fifty-nine percent of patients were taken to the operating room for incision and drainage, 52% of the patients had cultures taken of the abscess, and 35% of patients were given antibiotics coupled with incision and drainage. The antibiotics offered adequate coverage when compared with the sensitivities of the organisms 73% of the time. The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time. CONCLUSION: The presence of MRSA in perirectal abscesses is underrecognized. Recent data has shown that incision and drainage combined with antibiotics offers a superior outcome in soft tissue abscesses caused by this organism. If cultures are not routinely taken at the time of incision and drainage, the institutional incidents of MRSA will remain unknown. Physicians must recognize that MRSA is a potential organism present in perirectal abscesses when considering antimicrobial therapy for complex abscesses.", "provenance": [ { "field": "n", "quote": "In all, 124 patients were treated for perirectal abscess during the 8-year period." }, { "field": "design", "quote": "We conducted a retrospective study of all adult patients who presented with a perirectal abscess." }, { "field": "population", "quote": "all adult patients who presented with a perirectal abscess" }, { "field": "intervention", "quote": "35% of patients were given antibiotics coupled with incision and drainage" }, { "field": "comparator", "quote": "The antibiotics offered adequate coverage when compared with the sensitivities of the organisms 73% of the time." }, { "field": "primaryOutcome", "quote": "The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time." }, { "field": "result", "quote": "The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time." } ] }, { "id": "pmid:19143149", "pmid": "19143149", "doi": null, "nctId": null, "pmcid": null, "title": "[Cryptoglandular anal fistulas]", "firstAuthor": "de Parades", "multipleAuthors": true, "journal": "Rev Prat", "year": 2008, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with cryptoglandular anal fistulas (a type of perianal infection)", "intervention": "incision of the abscess under local anaesthesia, followed by surgical fistulotomy", "comparator": "antibiotic therapy alone, or sphincter-preserving techniques (rectal flap, fibrin glue)", "primaryOutcome": "getting rid of the infection and preventing recurrence", "result": "Antibiotics are not useful for initial treatment; the abscess needs urgent surgical incision, and surgical fistulotomy is very effective but can risk incontinence, leading to interest in sphincter-sparing alternatives", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a narrative review describing general management principles without original patient data or comparative results.", "directness": "direct", "limitations": "No original data, no patient numbers, no study design described, and no quantified outcomes are reported.", "followUp": "", "plainFinding": "Surgery needed; antibiotics alone not enough.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19143149/", "sourceText": "Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.", "provenance": [ { "field": "population", "quote": "Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis." }, { "field": "intervention", "quote": "consists of its incision under local anaesthesia" }, { "field": "intervention", "quote": "surgical fistulotomy" }, { "field": "comparator", "quote": "Antibiotic therapy is not of use in initial management except in special cases." }, { "field": "comparator", "quote": "sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue" }, { "field": "primaryOutcome", "quote": "aims to dry up the purulent discharge and avoid recurrence of the abscess" }, { "field": "result", "quote": "Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia." }, { "field": "result", "quote": "These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence." } ] }, { "id": "pmid:19018464", "pmid": "19018464", "doi": "10.1007/s10151-008-0446-2", "nctId": null, "pmcid": null, "title": "Perianal abscess caused by Actinomyces: report of a case", "firstAuthor": "Magdeburg", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2008, "design": "case-series", "n": 1, "nField": "reported", "population": "A patient with a painless perianal mass", "intervention": "Surgical excision plus antibiotics", "comparator": "None", "primaryOutcome": "Healing of the perianal infection", "result": "The infection healed after surgery and antibiotics", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show whether avoiding surgery would work.", "directness": "indirect", "limitations": "Single case report of a rare bacterial cause of abscess; surgery was still performed, so it does not address nonsurgical treatment.", "followUp": "", "plainFinding": "Surgery plus antibiotics healed infection", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19018464/", "sourceText": "Most anal abscesses are caused by anal fistula and invasion of the surrounding tissues by a mixed colonic flora. The treatment comprises excision of the abscess and. if appropriate, fistulectomy. Primary anorectal actinomycosis and perianal actinomycosis are very rare and are caused by Actinomyces, which is a ubiquitous microaerophilic bacterium. Here we report a case of perianal actinomycosis. The patient had a short history of painless perineal induration without fever or leucocytosis with normal routine blood tests. After excision sulphur granules drained from the cavity and the pathological investigations were indicative of perianal actinomycosis. Appropriate surgery and antibiotic treatment healed the perianal infection. After elimination of other diagnoses, e.g. Crohn's disease, tuberculosis and malignant growths, this rare case of perianal actinomycosis should be kept in mind in the differential diagnosis of a painless perianal mass.", "provenance": [ { "field": "population", "quote": "The patient had a short history of painless perineal induration without fever or leucocytosis with normal routine blood tests." }, { "field": "intervention", "quote": "Appropriate surgery and antibiotic treatment healed the perianal infection." }, { "field": "comparator", "quote": "The treatment comprises excision of the abscess and. if appropriate, fistulectomy." }, { "field": "primaryOutcome", "quote": "Appropriate surgery and antibiotic treatment healed the perianal infection." }, { "field": "result", "quote": "Appropriate surgery and antibiotic treatment healed the perianal infection." }, { "field": "n", "quote": "report a case of perianal actinomycosis" } ] } ], "faqs": [ { "q": "Can antibiotics alone cure my anal abscess?", "a": "In the one trial that tested this in adults, antibiotics alone (with a needle draw-off) worked for some people, but the abscess came back much more often than when it was properly drained. Most abscesses still need to be opened and drained." }, { "q": "Should I ask my doctor for antibiotics instead of a drainage procedure?", "a": "You can ask, but based on the one adult trial, drainage works more reliably. Antibiotics are sometimes added alongside drainage, especially if you have a fever, diabetes, or a weakened immune system — that's a different situation from antibiotics replacing drainage entirely." }, { "q": "What happens if I leave the abscess untreated and just take antibiotics?", "a": "Case reports describe adults whose infection spread and worsened on antibiotics alone, eventually needing urgent surgery. An abscess is a pocket of pus; antibiotics often can't reach it well enough on their own." }, { "q": "Should I stop the antibiotics I've already been prescribed?", "a": "Don't stop any prescribed antibiotic on your own. The point here is that antibiotics alone shouldn't replace drainage — talk to whoever prescribed them about whether you also need the abscess drained." }, { "q": "Is needle aspiration a good middle ground between pills and full surgery?", "a": "One trial tested needle aspiration plus antibiotics against standard incision and drainage, and aspiration led to more recurrences (41% versus 15%). It may still be an option in some cases, but standard drainage worked better in this trial." } ], "patientTakeaway": "If you have an anal or anorectal abscess, the most reliable treatment found in this evidence is still having it drained by a doctor. Antibiotics alone can work for some people, but in the one trial that tested this directly, the abscess came back far more often without drainage. See a doctor promptly — don't wait on antibiotics alone, especially if you have fever, worsening pain, or diabetes.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Anal Canal\"[Mesh] OR anorectal[tiab] OR perianal[tiab] OR perirectal[tiab]) AND (\"Abscess\"[Mesh] OR abscess[tiab]) AND (\"Drainage\"[Mesh] OR \"incision and drainage\"[tiab] OR surgical[tiab] OR surgery[tiab]) AND (\"Anti-Bacterial Agents\"[Mesh] OR antibiotic*[tiab] OR antimicrobial*[tiab])" }, "pubmedQueryTranslation": "(\"Anal Canal\"[MeSH Terms] OR \"anorectal\"[Title/Abstract] OR \"perianal\"[Title/Abstract] OR \"perirectal\"[Title/Abstract]) AND (\"Abscess\"[MeSH Terms] OR \"Abscess\"[Title/Abstract]) AND (\"Drainage\"[MeSH Terms] OR \"incision and drainage\"[Title/Abstract] OR \"surgical\"[Title/Abstract] OR \"surgery\"[Title/Abstract]) AND (\"Anti-Bacterial Agents\"[MeSH Terms] OR \"antibiotic*\"[Title/Abstract] OR \"antimicrobial*\"[Title/Abstract])", "searchedOn": "2026-10-05", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "Can an Anal Abscess Be Treated Without Surgery?", "description": "One randomised trial (98 adults) found antibiotics alone failed more often than drainage for anorectal abscess. See what the evidence actually shows." }, "lastChecked": "2026-10-05", "lastChanged": "2026-10-05", "nextCheckDue": "2026-11-05", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-05" }, "status": "published" }