Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Can Common Antimicrobials Combat MRSA Abscesses?

N Engl J Med; 2017 Jun 29; Daum, Miller, et al

Publish date:

Clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) in conjunction with incision and drainage improves short-term outcomes in patients with an uncomplicated skin abscess when compared with incision and drainage alone, according to a recent study. The double-blind trial included outpatient adults and children. Participants with a skin abscess 5 cm or smaller in diameter were enrolled and after abscess incision and drainage, were randomly assigned to receive clindamycin, TMP-SMX, or placebo for 10 days. The primary outcome was clinical cure 7 to 10 days after end of treatment. Researchers found:

  • The study enrolled 786 participants; 505 (64.2%) adults and 281 (35.8%) children.
  • Staphylococcus aureus was isolated from 527 participants and methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 388 (49.4%) participants.
  • 10 days after therapy in the intention-to-treat population, the cure rate among those in the clindamycin group were similar to that in the TMP-SMX group (83.1% vs 81.7%, respectively) and both were higher vs the placebo group (68.9%).

Citation:

Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017;376:2545-55. doi:10.1056/NEJMoa1607033.

Commentary:

This important study shows that the addition of clindamycin or TMP-SMX provides a better outcome than incision and drainage alone. This result is consistent with what many clinicians choose to do, but contrary to conventional wisdom of the last few years, which recommended I&D without the use of antibiotics in small to moderate sized abscesses where the patient does not have systemic signs of infection. The recommendations to forgo antibiotics in the treatment of small and moderate sized abscesses comes form a combination of expert opinion along with the results of a number of small, underpowered studies that indicated no benefit to the use of antibiotics in addition to I&D for treatment of abscesses.1 The current Infectious Disease Society of America guidelines state, “The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based upon presence or absence of systemic inflammatory response syndrome (SIRS)…or who have failed initial antibiotic treatment or have markedly impaired host defenses or in patients with SIRS and hypotension.”2 The current study suggests that these guidelines may need to be revised and that we might consider the use of clindamycin or TMP-SMX, in addition to I&D, to improve cure rates for patients with skin abscesses <5cm. —Neil Skolnik, MD

  1. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med. 2010;56:283-7. doi:10.1016/j.annemergmed.2010.03.002.
  2. 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. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444.

This Week's Must Reads

Must Reads in Infectious Diseases