Clindamycin and trimethoprim-sulfamethoxazole equally effective for uncomplicated skin infections

1. Clindamycin or trimethoprim-sulfamethoxazole for 10-days was equally effective at achieving clinical cure of uncomplicated skin infections (cellulitis, abscess or both) at 7-10 days after completing therapy.

2. Rates of adverse events including diarrhea, nausea, vomiting, pruritus and rash were similar in both groups treated with antibiotics.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Cellulitis and abscesses are clinical conditions commonly encountered in the outpatient setting. Widespread use of antibiotics has led to the emergence of antibiotic resistant organisms, which are now being isolated in endemic communities. Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has led to a rise in cellulitis and abscesses in outpatient practices.

This multicenter, double-blinded, randomized controlled study examined the efficacy of two antibiotics on uncomplicated skin infections. Both antibiotics were chosen for their well-known activity against MRSA as well as low cost. Patients were randomized to 10-days of either clindamycin (250mg orally three times daily) or trimethoprim-sulfamethoxazole (TMP-SMX)(320mg-1600mg orally twice daily). The primary endpoint of clinical cure at the “test of cure” visit (7-10 days after completing antibiotics) was similar in both groups. Additionally, there was no difference noted between the two treatments in the subgroups of children, adults, or type of lesion (cellulitis, abscess, or both).

The results of this study are generalizable to populations of healthy outpatients diagnosed with cellulitis and/or abscess. Given the propensity for S.aureus infections to recur, the one month follow up period included in this study was inadequate to evaluate the long-term efficacy of both antibiotics. Nevertheless, this study is the first to closely examine and compare two commonly prescribed antibiotics for increasingly common skin infections. Future studies may focus on the possibility of long-term antibiotic prophylaxis regimens for patients with recurrent MRSA-related skin infections.

Click to read the study, published today in NEJM

Click to read an accompanying editorial in NEJM

Relevant Reading: Outpatient management of skin and soft tissue infections in the era of community-associated MRSA – CDC

In-Depth [randomized controlled trial]: This study included 524 patients with uncomplicated skin infections (cellulitis, abscesses, or both) randomized to 10-days of therapy with either clindamycin or TMP-SMX.  The primary endpoint of clinical cure by 7-10 days after completing therapy was achieved in 80.3% and 77.7% (p=0.52) for clindamycin and TMP-SMX, respectively. Baseline characteristics of both treatment groups were well-matched, including for race/ethnic group, age and type of lesion (cellulitis, abscess, or both). The most common isolate cultured was Staphylococcus aureus (41.4%) with the methicillin-resistant strain (MRSA) isolated in 77.0% of this group. Rates of side effects were similar in both groups and included diarrhea, nausea, vomiting, pruritus and rash.

Image: PD

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