{"id":659,"date":"2015-03-30T17:33:26","date_gmt":"2015-03-30T17:33:26","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=659"},"modified":"2017-08-21T11:52:25","modified_gmt":"2017-08-21T11:52:25","slug":"primary-care-corner-with-geoffrey-modest-md-treatment-of-skin-infections-in-era-of-mrsa","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/03\/30\/primary-care-corner-with-geoffrey-modest-md-treatment-of-skin-infections-in-era-of-mrsa\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Treatment of skin infections in era of MRSA"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

A study done in 4 centers (Univ of Chicago, San Francisco General Hosp, Harbor-UCLA , and Vanderbilt Univ Med Ctr) looked at the efficacy of clindamycin vs trimethoprim-sulfamethoxazole (TMP-SMX) for uncomplicated skin infections\u00a0(see\u00a0N Engl J Med 2015;372:1093-1103<\/strong>\u200b). The question was: which medication is preferred in the current era of community-acquired methicillin-resistant Staph aureus (MRSA), which seems to be extremely common around the country?<\/p>\n

\"Untitled\"<\/a><\/p>\n

Details:<\/p>\n

–524 patients, including 155 children. 30.5% with abscess (>5cm, in adults), 53.4% with cellulitis, 15.6% with both; the patients were\u00a052.3% male, 53.2% Black, 40.3% White, 28.6% Hispanic. Mean age 27.1. 29.6% children.<\/p>\n

–patients were randomized to clindamycin (adults at 300mg tid) or\u00a0TMP-SMX (on double-strength\u00a0tablet bid), all for 10 days. Pediatric doses adjusted by body weight<\/p>\n

—\u00a0of those with positive cultures (n=277), 217 had s. aureus [167 with MRSA, 77.0% of the staph infections, with 21 (12.4%)\u00a0resistant to clinda and 1 resistant to\u00a0TMP-SMX; 52 were methicillin sensitive]; 32 were strep of different varieties; 10 were proteus, 38 coagulase-negative staph, 15 diphteroids, and a smattering of others. Note: all of the cultures were from those with abscesses, not cellulitis (cellulitis being 53.4% of the skin infections)<\/p>\n

–no difference in outcomes between these medications: 80.3% were cured with clindamycin, 77.7% with\u00a0TMP-SMX in intention-to-treat analysis, but in the 466 evaluable patients, it was 89.5% with clindamycin and 88.2% with\u00a0TMP-SMX.<\/p>\n

–no difference in children vs adults, in those with abscesses vs cellulitis. also no difference in subgroups infected with s. aureus, MRSA, or MSSA. of the 15 patients with\u00a0clindamycin-resistant staph, 11 were cured (73.3%) vs 91.7% of those sensitive to clinda<\/p>\n

–adverse events: similar: 18.9% with\u00a0TMP-SMX\u200b \u00a0and 18.6% with clindamycin, with both antibiotics associated with\u00a0diarrhea in about 10%, nausea 2.5%, pruritus in 1.5%, rash in 1%. no cases of clindamycin-associated c. diff infections.<\/p>\n

So, a few points:<\/p>\n

–It is pretty remarkable how well\u00a0TMP-SMX did, since a reasonable percentage of the patients had strep which is felt not to be sensitive to\u00a0TMP-SMX. And, it is generally held that cellulitis is much\u00a0more likely than abscesses to be caused by strep (though we cannot really culture cellulitis), yet the cure rate with\u00a0TMP-SMX\u00a0was the same for cellulitis and abscesses. there is some literature suggesting that the way sensitivity testing is done may underestimate\u00a0TMP-SMX sensitivity. [As a general point, agar-plate antibiotic resistance is not always an accurate reflection of what happens in the body. For example, many organisms causing urinary tract infections\u00a0seemingly resistant to antibiotics may in fact\u00a0respond, perhaps related to the high concentration of antibiotics in the urine]<\/p>\n

–Several studies have found that antibiotics do not add much to the primary treatment of abscesses (which is:\u00a0incision and drainage,\u00a0I&D), so the high cure rate with any antibiotic may not be\u00a0surprising. So, for example, 73.3% of those with clindamycin-resistant staph in the above study\u00a0“responded” to antibiotics, but these bacterial isolates were from abscesses and may not have needed antibiotics. But I should add that the literature on this is\u00a0really all over the place. Some studies suggest that abscesses> 5cm (as in the above study)\u00a0do better with antibiotics in addition\u00a0to I&D. Some find that MRSA infections in particular\u00a0respond better when antibiotics are added. but there are studies to the contrary.<\/p>\n

–There have been studies finding that cephalosporins or other b-lactam antibiotics with anti-strep activity\u00a0work somewhat better than\u00a0TMP-SMX for skin infections, though given the very high prevalence of MRSA that\u00a0we find at our health center, we have been mostly using\u00a0TMP-SMX\u00a0as the primary agent and\u00a0with good results\u200b (again, we only culture\u00a0those with abscesses). I had a patient with morbid obesity and\u00a0diabetes a few years ago\u00a0who had\u00a0a very large inner thigh abscess and surrounding cellulitis\u00a0from documented\u00a0MRSA, sent home from the hospital on linezolid, but I was unable to get the required prior approval\u00a0and switched him to TMP-SMX\u200b, and he had\u00a0a great result… In general, we do usually add antibiotics for skin infections because of the articles suggesting benefit in MRSA, and there was\u00a0even an article suggesting less likely recurrences if use\u00a0TMP-SMX\u200b.<\/p>\n

Note: I have\u00a0several other articles in the BMJ online blogs on MRSA, including the use of bleach baths, the new Infectious Disease Society guidelines on treatment of skin infections, and skin abscess treatment. See here<\/a>.\u00a0\u200b<\/p>\n","protected":false},"excerpt":{"rendered":"

Treatment of skin infections in era of MRSA […]<\/p>\n

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