Archive for May 16, 2015

Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections.

N Engl J Med March 19, 2015 V.372  P.1093-1103

Loren G. Miller, M.D., M.P.H., Robert S. Daum, M.D., C.M., C. Buddy Creech, M.D., M.P.H., David Young, M.D., Michele D. Downing, R.N., M.S.N., Samantha J. Eells, M.P.H., Stephanie Pettibone, B.S., Rebecca J. Hoagland, M.S., and Henry F. Chambers, M.D. for the DMID 07-0051 Team

From the Los Angeles Biomedical Research Institute (L.G.M., S.J.E.) and Division of Infectious Diseases, Harbor–UCLA (University of California, Los Angeles) Medical Center (L.G.M., S.J.E.), Torrance, David

Geffen School of Medicine at UCLA, Los Angeles (L.G.M., S.J.E.), Division of Plastic and Reconstructive Surgery, University of California, San Francisco (UCSF) (D.Y.), and Division of Infectious Diseases, San Francisco General Hospital and UCSF (M.D.D., H.F.C.), San Francisco — all in California; Division of Pediatric Infectious Diseases, University of Chicago, Chicago (R.S.D.); Division of Pediatric Infectious Diseases, Vanderbilt University, Nashville (C.B.C.); the EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.J.H.). Address reprint requests to Dr. Miller at the Division of Infectious Diseases, Harbor–UCLA Medical Center, 1000 W. Carson St., Box 466, Torrance, CA 90509, or at lgmiller@ ucla.edu    

BACKGROUND

Skin and skin-structure infections are common in ambulatory settings. However, the efficacy of various antibiotic regimens in the era of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is unclear.

METHODS

We enrolled outpatients with uncomplicated skin infections who had cellulitis, abscesses larger than 5 cm in diameter (smaller for younger children), or both. Patients were enrolled at four study sites. All abscesses underwent incision and drainage. Patients were randomly assigned in a 1:1 ratio to receive either clindamycin or trimethoprim–sulfamethoxazole (TMP-SMX) for 10 days. Patients and investigators were unaware of the treatment assignments and microbiologic test results. The primary outcome was clinical cure 7 to 10 days after the end of treatment.

RESULTS

A total of 524 patients were enrolled (264 in the clindamycin group and 260 in the TMP-SMX group), including 155 children (29.6%). One hundred sixty patients (30.5%) had an abscess, 280 (53.4%) had cellulitis, and 82 (15.6%) had mixed infection, defined as at least one abscess lesion and one cellulitis lesion. S. aureus was isolated from the lesions of 217 patients (41.4%); the isolates in 167 (77.0%) of these patients were MRSA. The proportion of patients cured was similar in the two treatment groups in the intention-to-treat population (80.3% in the clindamycin group and 77.7% in the TMP-SMX group; difference, −2.6 percentage points; 95% confidence interval [CI], −10.2 to 4.9; P=0.52) and in the populations of patients who could be evaluated (466 patients; 89.5% in the clindamycin group and 88.2% in the TMP-SMX group; difference, −1.2 percentage points; 95% CI, −7.6 to 5.1; P=0.77). Cure rates did not differ significantly between the two treatments in the subgroups of children, adults, and patients with abscess versus cellulitis. The proportion of patients with adverse events was similar in the two groups.

CONCLUSIONS

We found no significant difference between clindamycin and TMP-SMX, with respect to either efficacy or side-effect profile, for the treatment of uncomplicated skin infections, including both cellulitis and abscesses. (Funded by the National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, National Institutes of Health; ClinicalTrials.gov number, NCT00730028.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1403789

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May 16, 2015 at 11:44 am

Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus

N Engl J Med March 13, 2014 V.370 P.1039-1047

REVIEW ARTICLE

Adam J. Singer, M.D., and David A. Talan, M.D.

From the Department of Emergency Medicine, Stony Brook University, Stony Brook, NY (A.J.S.); the Departments of Emergency Medicine and Medicine, Division of Infectious Diseases, Olive View–UCLA Medical Center, Sylmar, CA (D.A.T.); and the David Geffen School of Medicine at UCLA, Los Angeles (D.A.T.).

Address reprint requests to Dr. Singer at the Department of Emergency Medicine, Stony Brook University, HSC-L4-080, Stony Brook, NY 11794-8350, or at adam.singer@stonybrook.edu

Abscesses are one of the most common skin conditions managed by general practitioners and emergency physicians.

The incidence of skin abscesses has increased, and this increase has coincided with the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA).

In many parts of the world, MRSA infections are now the most common cause of skin abscesses.6 Community-associated MRSA has also been found to cause severe infections — including necrotizing pneumonia, necrotizing fasciitis, purpura fulminans, and severe sepsis — in nonimmunocompromised hosts; however, its apparently increased virulence as compared with that of health care–associated strains and methicillin-susceptible S. aureus is incompletely understood.

Along with the increases in the incidence of skin abscesses and MRSA infections, other changes that potentially affect abscess care have occurred. Bedside ultrasonography has become increasingly available in emergency departments and hospitals. Traditional surgical practices have been systematically tested, and new techniques developed.

Prevention strategies have also been investigated. Despite these changes, the management of skin abscesses is highly variable……

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMra1212788

 

May 16, 2015 at 11:42 am


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