Management of Buttock Abscess in Penicillin-Allergic Patients

Primary Management: Incision and Drainage

Incision and drainage is the cornerstone of treatment and must be performed regardless of antibiotic selection, as recommended by the Infectious Diseases Society of America 1, 2
The decision to add antibiotics should be based on presence of SIRS criteria (temperature >38°C or <36°C, tachycardia >90 bpm, tachypnea >24 breaths/min, WBC >12,000 or <4,000 cells/µL) 1, 2

The American Academy of Pediatrics recommends clindamycin as the single best agent because it provides excellent coverage against both MRSA and beta-hemolytic streptococci 1, 4, 2
Clindamycin should be dosed at 300-450 mg orally four times daily for 7 days 3
Only use clindamycin if local MRSA clindamycin resistance rates are <10% 3
Trimethoprim-Sulfamethoxazole (TMP-SMX) is an acceptable alternative at 1-2 double-strength tablets (160/800 mg) twice daily for 7 days, but lacks reliable coverage against beta-hemolytic streptococci 1, 2
Doxycycline 100 mg twice daily for 7 days is another option for penicillin-allergic patients, but provides variable streptococcal activity 1, 2

Standard duration is 7 days for uncomplicated abscesses after adequate drainage, as recommended by the Infectious Diseases Society of America 3
Clinical improvement should be evident within 48-72 hours; if not, consider inadequate drainage, deeper infection, or resistant organism 3

Antibiotics are indicated if abscess cavity or surrounding erythema ≥5 cm diameter, presence of SIRS criteria, multiple abscesses or recurrent infections, significant surrounding cellulitis, immunocompromised state or diabetes, or difficult anatomic location 1, 2
Drainage alone may suffice if simple abscess <5 cm without extensive cellulitis, no systemic signs, and immunocompetent patient 1, 2

Obtain culture of abscess fluid to guide therapy, though empiric treatment is reasonable, as recommended by the Infectious Diseases Society of America 1, 2
Culture results allow de-escalation if methicillin-susceptible S. aureus is isolated 1

Do not use TMP-SMX alone if significant surrounding cellulitis is present due to poor streptococcal coverage, as warned by the American Academy of Pediatrics 4
Do not underdose clindamycin—300-450 mg four times daily is required, not three times daily, as recommended by the Infectious Diseases Society of America 3
Do not skip incision and drainage—antibiotics alone have poor efficacy for abscesses, as emphasized by the Infectious Diseases Society of America 1, 2