Treatment of Buttock Abscess in Children
Amoxicillin-clavulanate (Amox CV) is NOT the appropriate antibiotic choice for buttock abscesses in children; clindamycin is the preferred agent because it provides essential coverage against both community-acquired MRSA and anaerobic bacteria that commonly cause these infections. 1
Primary Treatment: Incision and Drainage First
The cornerstone of treatment is incision and drainage, which must be performed regardless of abscess size, with thorough evacuation of pus and probing to break up loculations. 1 This surgical intervention is mandatory and cannot be replaced by antibiotics alone, as antibiotic therapy without drainage will fail regardless of which agent is chosen. 1
When to Add Antibiotics
Antibiotics should be added to incision and drainage if ANY of the following criteria are present: 1
- Temperature >38.5°C
- Heart rate >100-110 beats/minute
- White blood cell count >12,000 cells/µL
- Extensive surrounding cellulitis
- Multiple sites of infection
- Immunocompromised status
- Inability to completely drain the abscess
For simple abscesses after adequate drainage in immunocompetent children without systemic signs, antibiotics are generally not needed. 1
Why Clindamycin Over Amoxicillin-Clavulanate
Buttock/perianal abscesses are considered complex due to polymicrobial flora including anaerobes from adjacent bowel flora, typically involving both Staphylococcus aureus (including community-acquired MRSA) and anaerobic organisms. 1
Clindamycin provides dual coverage that is particularly valuable for this anatomic location: 1
- Covers community-acquired MRSA (which amoxicillin-clavulanate does NOT cover)
- Covers anaerobic bacteria from bowel flora
The recommended clindamycin dosing is 10-13 mg/kg/dose every 6-8 hours, with a maximum of 40 mg/kg/day for 5-7 days based on clinical response. 1
Alternative Broader Spectrum Options
If the infection is severe or not responding to initial therapy, broader spectrum agents like cefoxitin or ampicillin-sulbactam may be considered for perianal locations. 1 However, these are second-line choices after clindamycin.
Critical Pitfalls to Avoid
- Never rely on antibiotics alone without drainage - this approach will fail regardless of antibiotic selection. 1
- Do not attempt needle aspiration - it has a low success rate of 25% and <10% with MRSA infections. 1
- Monitor for Clostridium difficile-associated diarrhea when using clindamycin, as it carries this risk. 1
- Search carefully for a coexisting fistulous tract at the time of primary drainage, as all recurrences in one pediatric series occurred in patients treated by drainage alone without fistulotomy. 2
Duration and Follow-Up
Treatment should last 5-7 days, with patients requiring diagnostic re-evaluation if signs of infection persist beyond 7 days. 1 Reassessment at 48-72 hours ensures adequate drainage and clinical improvement. 3