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Shooters Abscess

Matthieu DeClerck, MD and Jessica Osterman, MD

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Shooters abscesses tend to be larger and can lead to a more complicated incision and drainage than typical abscesses that present in the urgent care setting. Jess and Matt discuss common presentations, complications and management of these infections.



  • Shooters abscesses are due both to bacteria introduced by the needle as well as an inflammatory response to the drug which walls off an area that can be a nidus for infection.

  • Wound cultures and antibiotics are generally recommended for these abscesses.

  • The ED is a more appropriate place for treatment if these red flags are present:  signs of systemic toxicity, huge abscesses, evidence of necrotizing fasciitis or septic thrombophlebitis, and concern for wound botulism.


  • IV drug users are at high risk for abscesses due to:

    • The introduction of bacteria from a dirty needle or the skin.

    • A toxic inflammatory reaction to the drug which creates a walled-off area that becomes a nidus for infection.  Can be from:

      • Extravasation of drugs into the surrounding tissue.

      • Injection into the fatty layer under the skin due to inability to find a vein (“skin-popping”). 

      • Tissue necrosis due to toxic materials in drugs.

  • Diagnosis: 

    • Presents similar to non-shooters abscesses with redness, warmth, tenderness and fluctuance.

    • Deeper abscesses (due to deeper injection) may not have typical redness and warmth.

    • Can have lymphedema.

  • Treatment considerations: 

    • Mainstay of treatment is incision and drainage

      • Consider doing an x-ray to rule out a retained needle fragment.

      • If ultrasound is available, use it to rule out vascular malformation (with color doppler flow) and to help identify the best incision location.

      • Have suction ready because these are often large volume abscesses. 

      • Can be helpful to decompress the abscess by first aspirating pus out prior to making an incision.

      • Use hemostats to break up loculations (NEVER use a finger).

      • Packing is controversial. May have a benefit for larger abscesses (>5 cm).

      • An alternative to packing is a loop drainage technique.

        •  Link to ERCAST video of this procedure.

      • All patients should have follow-up in 24-48 hours.

    •  Would culture may be of benefit in this population, especially if:

      • Severe local infection

      • Systemic signs of infection

      • History of recurrent or multiple abscesses

      • Failure of antibiotic treatment

      • Immunocompromised

    • Antibiotics are recommended after I&D (since there often is overlying cellulitis and these deep abscesses carry a risk of incomplete evacuation).

      • Bugs:

        • MRSA is one of the most common pathogens.

        • IV drug users are more likely to have streptococci and anaerobes (due to licking needles).

        • Infections are often polymicrobial.

      • Drugs:

        • Single agent PO choices are clindamycin, doxycycline, or trimethoprim-sulfamethoxazole.

    • Update tetanus immunization as needed.

  • Red flags which indicate a need for a higher level of care:

    • Signs of systemic infection (fever, tachycardia, hypotension)

    • Huge abscesses with significant surrounding cellulitis

      • Drainage may not be efficient in the urgent care.

      • IV antibiotics are often necessary.

    • Evidence of necrotizing fasciitis 

      • Crepitance

      • Pain out of proportion to exam

      • Rapidly expanding erythema

      • Abnormal vital signs

    • Septic thrombophlebitis

      • Redness/swelling/tenderness over a vein

      • Pus draining from a vein

      • Abnormal vital signs

    • Neurologic abnormalities

      • Raises concern for wound botulism

      • Black tar heroin has a high risk of contamination with botulism.



  1. Jenkins TC, et al. Microbiology and initial antibiotic therapy for injection drug users and non-injection drug users with cutaneous abscesses in the era of community-associated methicillin-resistant Staphylococcus aureus. Acad Emerg Med. 2015 Aug;22(8):993-7. PMID: 26202847.

  2. Spelman, Denis et al.  Cellulitis and skin abscess in adults: Treatment.  UpToDate, April 1 2019.

  3. Stanway, Amy.  Skin infections in IV drug abusers. 2002

  4. Hakkarainen TW, et al. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug;51(8):344-62. PMID: 25069713.

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