Abscess Management for the Healthcare Team Materials

ABSCESS MANAGEMENT: A GUIDE FOR THE HEALTHCARE TEAM

Austin Fredrickson, MD, FACP

Austin Fredrickson is an Associate Professor of Internal Medicine at NEOMED and is a board-certified general internal medicine physician.

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy.

Topic Overview

Abscesses are collections of pus in the dermis or deeper skin tissues and are commonly caused by methicillin-resistant Staphylococcus aureus (MRSA) infections. Furuncles, or boils, result from staphylococcal infections that affect a hair follicle and the surrounding tissue. Treatment of abscesses requires understanding their common risk factors, pathophysiology, etiology, and epidemiology, as well as knowledge of clinical manifestations and diagnosis. Additionally, effective abscess management requires a comprehensive, patient-centered approach facilitated by a well-coordinated interprofessional care team. The Interprofessional Education Collaborative (IPEC) competencies provide a framework to optimize collaboration among healthcare professionals. These competencies are critical to ensuring safe, efficient, and high-quality care. When healthcare professionals respect each other's expertise, work cohesively, and prioritize the patient’s well-being, outcomes are optimized. By integrating evidence-based practices and fostering collaboration, healthcare teams can achieve better outcomes and minimize complications for patients with abscesses.

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Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: December 30, 2024 Expiration Date: December 30, 2027

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How to Earn Credit: From December 30, 2024, through December 30, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe clinical manifestations of abscesses

Recall treatment strategies for furuncles and carbuncles

Compare and contrast antibiotics used in the management of abscesses

Educate patients and caregivers on the appropriate management of abscesses

Describe the collaborative roles and responsibilities of healthcare professionals, including pharmacists and physicians, in the diagnosis and treatment of abscesses

Disclosures

The following individuals were involved in developing this activity: Liz Fredrickson, PharmD, BPCS, Austin Fredrickson, MD, FACP, and Pamela Sardo, PharmD, BS. Pamela Sardo, Liz Fredrickson, and Austin Fredrickson have no conflicts of interest or financial relationships regarding the subject matter discussed. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

Abscess Management: A Guide for the Healthcare Team Introduction

Abscesses are collections of pus in the dermis or deeper skin tissues and are commonly caused by methicillin-resistant Staphylococcus aureus infections. Furuncles, or boils, result from staphylococcal infections that affect a hair follicle and the surrounding tissue. This course provides an overview of the common risk factors, pathophysiology, etiology, and epidemiology of abscesses. The clinical manifestations and diagnosis of abscesses will also be reviewed within a patient-centered approach that uses an interdisciplinary healthcare team framework.

Defining Abscesses

Abscesses are collections of pus in the dermis or deeper skin tissues. They can form in other areas of the body, but this review will focus on skin and soft tissue abscesses. Abscesses are commonly caused by methicillin- resistant Staphylococcus aureus (S. aureus), known as MRSA infections.1,2 Abscesses can also be caused by methicillin-sensitive S. aureus (MSSA), which is susceptible to beta-lactam antibiotics and presents with fewer barriers to treatment than MRSA.1

Beyond MRSA and MSSA, other bacteria, such as anaerobes and Streptococcus species, can also contribute to abscess formation. Nonbacterial pathogens such as viruses, fungi, and parasites can cause abscesses, but this is less likely. There are different types of abscesses, including furuncles and carbuncles. Furuncles, or boils, result from infections that affect a hair follicle and the surrounding tissue. Carbuncles are larger clusters of interconnected furuncles beneath the skin, leading to deeper infection, suppuration, and potential scarring.3

Classification of SSTIs

Skin and soft tissue infections (SSTIs) are a heterogeneous group of diseases that can pose significant challenges for patients in community and hospital settings.4 Although the incidence rate of SSTIs has remained stable, effective treatment of SSTIs can significantly reduce disease morbidity and the utilization of healthcare services.5 Skin and soft tissue infections, including abscesses, are associated with important terminology and abbreviations with which the healthcare team should be familiar. These are defined in Table 1.

Table 1

SSTI Terminology5-8

Skin and soft tissue infections can be categorized as primary or secondary.6 In the case of primary bacterial skin infections, areas of skin that were once healthy are infected by a single pathogen.6 Conversely, secondary skin infections involve infection of previously damaged skin and are typically caused by multiple bacteria (polymicrobial).6 SSTIs can also be classified as

uncomplicated (simple) or complicated (necrotizing or non-necrotizing).6,9,10 Examples of simple infections include cellulitis, erysipelas, folliculitis, furuncles, and carbuncles.7 Furuncles and carbuncles occur when follicular infections extend to the subcutaneous area of the skin.6

With complicated infections, deeper skin structures, such as facia, are infected, and patients often require surgery.5 Examples include deep abscesses, decubitus ulcers, and necrotizing fasciitis.9 Patients with complicated infections are also commonly immunocompromised in some manner and may have conditions such as diabetes or human immunodeficiency virus (HIV).6 These infections can be classified according to their severity, need for therapeutic intervention, and the presence of comorbidities. Table 2 details this classification system.9

Table 2 Classification of SSTIs9

Etiology and Epidemiology

Within the United States (US), SSTIs result in over 14 million outpatient visits and nearly 900,000 inpatient admissions annually, contributing between 3% and 30% of all emergency department (ED) visits.5-7 An increase in community-associated methicillin-sensitive S. aureus (MSSA) has been seen in conjunction with increases in ED visits secondary to abscesses within recent years.11

As stated, abscesses are most frequently caused by S. aureus, which can present as MSSA or MRSA.1-3 Risk factors for MRSA include intravenous drug use, homelessness, dental disease, contact sports, incarceration, and previous MRSA infection and colonization.1-3 However, not every patient will present with MRSA risk factors. One study examining the management of skin abscesses treated in the emergency department found no significant correlation between the extent of surrounding cellulitis or the size of the abscess and the likelihood of obtaining MRSA-positive cultures.12 This calls into question the ongoing myth that MRSA is “bigger” or “worse” than MSSA, but this claim is not backed up by evidence.12

Furuncles and carbuncles can appear in younger, healthy individuals but are more frequently observed in patients who are obese, have compromised immune systems (e.g., neutrophil dysfunction), are older, and/or have diabetes.3 Contributing factors include bacterial colonization on the skin or nasal passages, hot and humid climates, and blocked or abnormal hair follicles (e.g., comedones in acne).3 Effective interprofessional collaboration is critical to identifying risk factors and addressing health determinants such as homelessness, intravenous drug use, and access to care, which are significant risk factors for MRSA.

Pathophysiology of SSTIs and Abscesses

Healthy skin is a primary defense mechanism against infections and a barrier between humans and their environment.6 It supports a diverse microbiome of bacteria and fungi and several host factors that protect against

infections.6 The continuous renewal of the epidermal layer leads to the shedding of skin bacteria, and sebaceous secretions are hydrolyzed to form free fatty acids, inhibiting bacterial growth.6 Additionally, the commensal skin microbiome prevents colonization by more pathogenic bacteria.6

Factors that can predispose a person to skin infections include the following:6

High concentrations of bacteria (more than 105 microorganisms)

Excessive moisture of the skin

Inadequate blood supply

Availability of bacterial nutrients

Damage to the corneal layer, allowing bacterial penetration

Although the skin and subcutaneous tissues are typically highly resistant to infections and, under certain conditions, they can become vulnerable.6 Intact skin is the best defense against SSTIs, as most occur due to the disruption of normal host defenses through skin puncture, surgery, increased tissue tension secondary to fluid stasis, or underlying diseases such as diabetes.6,9 Skin and soft tissue infections can either initiate from a neighboring site or be due to embolic spread from a site further away.9

Clinical Presentation and Diagnosis

Effective abscess diagnosis and management requires a comprehensive, patient-centered approach facilitated by a well-coordinated interprofessional care team. The Interprofessional Education Collaborative (IPEC) for Interprofessional Collaborative Practice competencies provides a framework to optimize collaboration among healthcare professionals.13 The IPEC comprises 22 professional organizations that represent the majority of health profession education programs in the United States, and these competencies are critical to ensuring safe, efficient, and high-quality care.13

Signs and Symptoms of Skin and Soft Tissue Infections

Common signs and symptoms of SSTIs include erythema (redness), warmth, edema, and pain at the affected site.9 Patients may also have systemic signs of infection, which indicates the severity and magnitude of the infection.9 Such signs include fever and other systemic manifestations.9 Furuncles are commonly found on the face, breast, neck, and buttocks and appear as nodules or pustules.3 Patients can experience pain and discomfort if attached to a structure such as the nose or finger.3 Carbuncles are clusters of furuncles, and patients may experience fever.3 The clinical presentation of furuncles and carbuncles is described in Table 3, and a photograph of an unruptured skin abscess is pictured in the image below.4

Table 3

Clinical Presentation of Furuncles and Carbuncles6

Skin Abscess14

Diagnosing Abscesses

The diagnosis of abscesses should begin with a thorough patient history to identify potential risk factors.9 The physical examination involves inspecting the affected area for signs of infection, including erythema, edema,

tenderness, and the presence of any lesions.9 Lesions can be cultured.3 The differential diagnosis for abscesses is presented in Table 4.1

Table 4

Differential Diagnosis for Abscesses1

Management of Abscesses Collaborative Practice Considerations

To promote optimal patient outcomes, it is essential for team members to clearly understand and differentiate their roles, scopes of practice, and responsibilities. As such, teams should implement collaborative care plans delineating roles, responsibilities, and timelines for managing abscesses.15 These plans include input from all team members—physicians, pharmacists, nurses, care coordinators, and social workers—to ensure that care is timely, efficient, and equitable.15 For example, in patients with recurrent abscesses, these plans might integrate pharmacists’ recommendations for antimicrobial stewardship and social workers’ input on addressing social determinants of health.15

Clear communication within the care team will also help ensure the appropriate application of evidence-informed guidelines. This will foster efficient collaboration and minimize redundancy, ensuring that each professional’s unique expertise contributes to patient-centered care. Constructive feedback within the team can help refine these processes, and active listening and shared decision-making together allow for alignment on goals, ensuring timely and effective care.

Additionally, cultural humility is vital to building trust and engaging patients effectively, particularly in diverse populations or underserved communities.16 Team members must recognize and respect cultural beliefs and practices that may influence health-seeking behaviors, such as reluctance to undergo invasive procedures or challenges adhering to prescribed regimens due to language barriers or health literacy issues.16 Team members can increase their focus on addressing social determinants of health and risk factors, such as access to care, smoking, obesity, and economic barriers, that contribute to recurrent abscesses. This shift could involve scheduling regular multidisciplinary meetings to discuss high-risk patients. Collaborative communication and shared decision-making tailored to the patient’s cultural context can enhance adherence and satisfaction with care.

Table 5 describes common barriers and solutions to interprofessional collaborative practices in the context of abscess management.

Table 5

Barriers and Solutions to Interprofessional Collaborative Practice

Guideline and Panel Recommendations

The IDSA guidelines recommend not starting antibiotics for patients with uncomplicated lesions post-incision and drainage.17 More recently, an

international panel formed new recommendations that investigated the use of antibiotics for abscesses based on benefits, risks, cost, quality of available evidence, and patient preferences.18 These new guidelines are intended for adults and children who have uncomplicated skin abscesses, including the following:18

Abscess of any size

First occurrence or recurrence of an abscess

An abscess caused by an unknown pathogen

Selected antibiotics should be effective against MRSA.3,18 The panel found that the use of trimethoprim/sulfamethoxazole (TMP-SMX) or clindamycin, in combination with incision and drainage, reduces the risk of treatment failure by about 5% at one month and recurrence by approximately 8% at three months, compared to using no antibiotics. Moderate-quality evidence found both antibiotics reduce pain, hospitalizations, and infections in household contacts.18 There is no significant difference in treatment failure or recurrence rates between TMP-SMX and clindamycin.18 TMP-SMX, taken twice daily, is typically inexpensive, while clindamycin, taken three to four times daily, may be costly in some areas.18

Adverse effects also differ between these antibiotics.18 Clindamycin is associated with a higher risk of diarrhea and gastrointestinal issues, while TMP-SMX is associated with nausea and a lower risk of diarrhea.18 TMP-SMX may be preferred for patients wanting to avoid gastrointestinal side effects, while clindamycin might be more suitable for those prioritizing recurrence prevention.14 Patient preferences should guide the decision.18 Overall, the panel gave a weak recommendation favoring TMP-SMX over clindamycin, with either antibiotic preferred over incision and drainage (I&D) alone.18

Notably, cephalosporins do not reduce treatment failure rates compared to incision and drainage alone, even in areas with high MRSA rates.18 Consequently, the panel strongly advises against cephalosporin use, as TMP- SMX or clindamycin are more effective.18

General Management Strategies

Managing abscesses effectively requires a collaborative approach to ensure patient-centered, safe, and efficient care. The following recommendations provide a framework for treatment and highlight the critical roles of team members, guided by communication and teamwork competencies.2,5

Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without cultures is reasonable in most patients.

Carbuncles, abscesses, and large furuncles of mild severity should be treated with incision and drainage. Communication between team members ensures procedures are conducted promptly.

Administration of antibiotics with activity against S. aureus as an adjunct to incision and drainage should be based on the presence or absence of systemic signs of infection.

Antibiotic therapy is required for abscesses that are associated with extensive cellulitis, rapid progression, or poor response to initial drainage; that involve specific sites (e.g., face, hands, genitalia); and that occur in children and older adults or in those who have significant comorbid illness or immunosuppression.

Antibiotics with activity against MRSA are recommended for patients with carbuncles or abscesses of higher severity who have failed initial antibiotic therapy, have severe systemic signs of infection, or are immunocompromised. Appropriate selection of antibiotics by the care team ensures safety and efficacy through antimicrobial stewardship practices.

Treating these infections involves using local care measures, such as warm, moist compresses.5 Topical therapies can be tried, including clindamycin, erythromycin, mupirocin, or benzoyl peroxide.4 These should be applied 2-4 times daily for one week.5 If furuncles are small, they can be treated with moist heat to encourage pus drainage, while larger furuncles and carbuncles may need to be incised and drained.5

Antibiotics are generally unnecessary for single lesions less than 5mm in size; however, more severe infections require antibiotic therapies.3 Systemic antibiotics should be considered for the following:3

Lesions > 5 mm or < 5 mm that do not resolve with drainage

Multiple lesions

Evidence of expanding cellulitis

Immunocompromised patients

Patients at risk of endocarditis

Fever

Options include trimethoprim-sulfamethoxazole, doxycycline, or minocycline for 5-10 days.3 These antibiotics will cover any potential MRSA.3 Often, these infections will resolve without medical or surgical involvement.3,5 Patients who require but do not respond to systemic antibiotic therapies or have recurrent infections will need culture and sensitivity testing to guide further antibiotic therapies.3,5

Table 63

Treatment of Furuncles and Carbuncles

Recurrent Abscesses

It is common for furuncles to recur.3 Patients can prevent recurrences by using hand soap with either chlorhexidine gluconate with isopropyl alcohol or 2-3% chloroxylenol.3 It is essential for the care team to address underlying factors such as obesity, diabetes, and occupational exposures for patients with recurring furuncles.3 In some cases, rifampin may be needed. Table 7 summarizes information from the ISDA regarding the prevention of abscesses.1

Table 7

Recommendation for the Prevention of Recurrent Abscesses1

Patient Education

Patient education regarding abscess care and prevention is crucial. By integrating interprofessional teamwork and communication strategies, healthcare teams can provide comprehensive patient education for abscesses, ultimately reducing recurrence and improving health outcomes. Strategies may include the following:19-21

Using non-technical language to ensure understanding and empower patients to participate in their care

Employing shared leadership by involving patients as active participants in their care plans

Reflecting on team performance to improve the effectiveness of patient education strategies and adjust as needed based on outcomes

Specifically, patients and/or caregivers should be educated that they should keep the abscess covered 24 hours a day and only remove bandages to wash the area once a day.22 Healthcare providers should inform patients to be cautious regarding the worsening of symptoms and to reach out to the care team if they notice any continued redness, pain, or purulent drainage.22 Additional counseling points are summarized in Table 8.23

Table 8

Patient Education for Abscesses23

Pharmacy Technicians

Pharmacy technicians play a vital role in supporting patients with SSTIs and more by performing tasks that ensure the smooth functioning of pharmacy operations and enhance patient care. They assist pharmacists by accurately filling prescriptions and ensuring that patients receive the correct medications in the appropriate doses. In addition to filling prescriptions, pharmacy technicians help manage inventory, ensuring that essential antibiotics and other related supplies are readily available. This involves monitoring stock levels, placing orders, and checking for expired medications, thereby maintaining a reliable supply of necessary treatments for SSTIs. Keeping the pharmacy well-stocked and organized can help prevent treatment delays and contribute to the overall efficiency of pharmacy services.

Summary

Effective management of abscesses requires a strong understanding of their associated risk factors and pathophysiology, as well as knowledge pertaining to diagnosis and available management strategies. Pharmacy team members play crucial roles in preventing and managing abscesses through interprofessional collaboration with healthcare teams and providing patient and caregiver education.

Course Test

Which of the following is a patient with a furuncle most likely to present with?

Multiple itchy, painful lesions

Firm, discrete, red nodule

Multiple, small lesions covering the extremities

Cellulitis, fever, and lymphangitis

Which of the following physical signs is commonly associated with carbuncles?

Presence of a single lesion

Presence of broad, swollen, deep follicular masses

Lack of systemic signs such as fever

Lesions that drain spontaneously

Which of the following indicates using systemic antibiotics to treat abscesses?

Lesions > 3 mm

Lesions that resolve with drainage

Evidence of expanding cellulitis

Immunocompetent patients

Which of the following is an appropriate management strategy for abscesses?

The treatment of abscesses always involves the use of systemic antibiotics

Large furuncles can be treated with moist heat to encourage drainage

Topical therapies, including clindamycin or mupirocin, can be prescribed

Small furuncles always require incision and drainage

Antibiotics should be effective in treating abscesses from

Staphylococcus aureus

Pseudomonas aeruginosa

Klebsiella pneumoniae

Haemophilus influenzae

Which antibiotic is commonly used to treat abscesses with suspected MRSA?

Amoxicillin

Cephalexin

Trimethoprim-sulfamethoxazole

Penicillin

Which antibiotic, used to treat furuncles and carbuncles, works by reversibly binding to 50S ribosomal subunits and preventing peptide bond formation?

Doxycycline

Minocycline

Trimethoprim-sulfamethoxazole

Clindamycin

Which of the following demonstrates shared decision-making in the interprofessional management of abscesses?

The physician unilaterally determines the treatment plan

The care team discusses the patient’s treatment options, considers the patient’s preferences, and develops a consensus-based care plan

The pharmacist prescribes antibiotics, consulting only the social worker on the care team

The nurse independently decides on wound care protocols without team input

Which of the following is an appropriate dose for trimethoprim- sulfamethoxazole in the treatment of furuncles?

100 mg orally every 12 hours

300 mg orally every 6 hours

600 mg orally every 8 hours

800/160 mg orally twice daily

Which of the following is a patient counseling point for patients with abscesses?

There are numerous self-care options to treat abscesses

Apply cold compresses every 30 minutes to reduce swelling

Take ibuprofen for pain and swelling

Avoid covering the infected area

References

Usatine RP. Abscess. In: Usatine RP, Smith MA, Mayeaux, Jr. EJ, Chumley HS. eds. The Color Atlas and Synopsis of Family Medicine, 3e. McGraw-Hill Education; 2019. Accessed October 23, 2024.

Huak L. Antibiotics for Uncomplicated Skin Abscesses After Incision and Drainage: BMJ Rapid Recommendation. Am Fam Physician. 2018;98(5):323-324.

MERCK Manual. Furuncles and Carbuncles. https://www.merckmanuals.com/professional/dermatologic- disorders/bacterial-skin-infections/furuncles-and-carbuncles. Accessed December 2, 2024.

Bouza E, Burillo A. Current international and national guidelines for managing skin and soft tissue infections. Curr Opin Infect Dis. 2022;35(2):61-71. doi:10.1097/QCO.0000000000000814

Blanes Hernández R, Rodríguez Pérez M, Fernández Navarro J, Salavert Lletí M. Current approach to skin and soft tissue infections. Thinking about continuity of care. Rev Esp Quimioter. 2023;36 Suppl 1(Suppl 1):37-45. doi:10.37201/req/s01.10.2023

Fish DN. Skin and Soft Tissue Infections. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023.

Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008;19(2):173-184. doi:10.1155/2008/846453

Wingate B, Kehr H. Management of Complicated Skin and Soft Tissue Infections in Hospitalized Patients. US Pharm. 2007;32(4):HS5-HS12

Ramakrishnan K et al. Skin and Soft Tissue Infections. Am Fam Physician. 2015;92(6):474-483.

Spelman D, et al. Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis. Uptodate. 2024.

Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA Jr. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298.

doi:10.1016/j.annemergmed.2007.12.004

Olderog CK, Schmitz GR, Bruner DR, Pittoti R, Williams J, Ouyang K. Clinical and epidemiologic characteristics as predictors of treatment failures in uncomplicated skin abscesses within seven days after incision and drainage. J Emerg Med. 2012;43(4):605-611. doi:10.1016/j.jemermed.2011.09.037

Interprofessional Education Collaborative. IPEC Core Competencies for Interprofessional Collaborative Practice: Version 3. Washington, DC: Interprofessional Education Collaborative. 2023.

Centers for Disease Control and Prevention. Coignard, B., Hageman, J. Public Health Image Library. Details. CDC. 2005. https://phil.cdc.gov/details.aspx?pid=7826. Accessed December 28, 2024.

Shallcross LJ, Hayward AC, Johnson AM, Petersen I. Incidence and recurrence of boils and abscesses within the first year: a cohort study in UK primary care. Br J Gen Pract. 2015;65(639):e668-76. doi: 10.3399/bjgp15X686929

Centers for Disease Control and Prevention. Health Equity and Antimicrobial Resistance. CDC. Undated. https://www.cdc.gov/antimicrobial-resistance/media/pdfs/Health- Equity-Antibiotic-Resistance-FS-508.pdf. Accessed December 2, 2024.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. doi: 10.1093/cid/civ114. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444

Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ. 2018;360:k243. Published 2018 Feb 6. doi:10.1136/bmj.k243

Langberg EM, Dyhr L, Davidsen AS. Development of the concept of patient-centredness - A systematic review. Patient Educ Couns. 2019;102(7):1228-1236. doi:10.1016/j.pec.2019.02.023

Montori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-making as a method of care. BMJ Evid Based Med. 2023;28(4):213-217. doi:10.1136/bmjebm-2022-112068

Anderson JE, Lavelle M, Reedy G. Understanding adaptive teamwork in health care: Progress and future directions. J Health Serv Res Policy. 2021;26(3):208-214. doi:10.1177/1355819620978436

Treatment of Your Abscess. University of California Berkley. Accessed December 2024. https://uhs.berkeley.edu/sites/default/files/AbscessTreatment.pdf . Accessed December 28, 2024.

Schmitz G, Goodwin T, Singer A, et al. The treatment of cutaneous abscesses: comparison of emergency medicine providers' practice patterns. West J Emerg Med. 2013;14(1):23-28. doi:10.5811/westjem.2011.9.6856

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