What is the management of pediatric subperiosteal abscess?

From the Guidelines

Management of pediatric subperiosteal abscess requires prompt surgical drainage combined with appropriate antibiotic therapy. Initial treatment should include broad-spectrum intravenous antibiotics such as clindamycin (10-13 mg/kg/dose every 8 hours) or a combination of ceftriaxone (50-75 mg/kg/day) plus metronidazole (30 mg/kg/day divided every 8 hours) while awaiting culture results, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• Surgical intervention is necessary in most cases, with CT or MRI imaging recommended prior to surgery to determine the extent of the abscess, as discussed in the Journal of the American College of Radiology 1.
• The procedure involves making an incision to access the abscess, draining the purulent material, and obtaining samples for culture.
• Following drainage, patients typically continue intravenous antibiotics for 24-48 hours until clinical improvement is observed, then transition to oral antibiotics (such as amoxicillin-clavulanate 45 mg/kg/day divided twice daily or clindamycin 30-40 mg/kg/day divided three times daily) to complete a 10-14 day course.
• Close follow-up is essential to monitor for resolution of symptoms and potential complications, as subperiosteal abscesses can rapidly progress to osteomyelitis, sepsis, or intracranial complications if not properly managed, as noted in the Clinical Infectious Diseases journal 1.

Antibiotic Selection

• The most common causative organisms include Staphylococcus aureus, Streptococcus species, and anaerobes, which guides the initial antibiotic selection.
• Clindamycin, TMP-SMX, doxycycline, and linezolid are potential options for empirical therapy, with the choice depending on local epidemiology and the type of infection, as discussed in the Clinical Infectious Diseases journal 1.

From the Research

Management of Pediatric Subperiosteal Abscess

• The management of pediatric subperiosteal abscess can be either medical or surgical, depending on the severity of the condition and the presence of complications 2, 3, 4, 5, 6.
• Medical management with intravenous antibiotics can be effective in treating subperiosteal abscess, especially in cases where the abscess is small and there are no signs of compromised optic nerve function 2, 3.
• Surgical drainage may be necessary in cases where the abscess is large, or where there are signs of complications such as proptosis, gaze restriction, or fever 3, 6.
• The choice of antibiotic therapy is important, with Streptococcus spp, Staphylococcus aureus, and anaerobic bacteria being common pathogens isolated from cultures 3, 6.
• Percutaneous drainage of subperiosteal abscess may be an alternative to surgical drainage in some cases, especially when medical therapy alone is inadequate 5.

Predictive Factors for Surgical Intervention

• Abscess volume appears to be a significant predictive risk factor for surgical intervention, with patients having larger abscesses being more likely to require surgery 6.
• Proptosis and gaze restriction are also significant predictors of surgical intervention, with patients exhibiting these symptoms being more likely to require surgery 6.
• Further studies are needed to provide more definitive values predictive of which patients are likely to fail medical therapy and require surgical intervention 6.

Microbiology and Antibiotic Therapy

• Streptococcus spp is the most frequently encountered bacteria in subperiosteal abscess, followed by Staphylococcus aureus and anaerobic bacteria 3.
• Antibiotic therapy should be adapted to the suspected or confirmed pathogens, with a combination of intravenous antibiotics such as a third-generation cephalosporin and metronidazole being commonly used 3.
• Oral treatment with amoxicillin-clavulanate may be used after initial intravenous therapy, with the duration of treatment depending on the severity of the condition and the response to therapy 3.