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TMP-SMX, clindamycin reduce recurrence of S. aureus skin infections
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The use of guideline-recommended antibiotics, such as trimethoprim/sulfamethoxazole and clindamycin, during incision and drainage of minor Staphylococcus aureus skin and soft tissue infections prevented bacterial colonization and reduced the risk of recurrent infections.
“There have been conflicting data about the benefit to antibiotics in minor staph infections,” Stephanie A. Fritz, MD, associate professor of pediatrics in the division of infectious diseases at Washington University, said in a press release. “It is definitely important to surgically remove pus from the infection site, but also giving antibiotics means that the child will be less likely to see a doctor again in several months for another staph infection.”
To assess whether systemic antibiotics in combination with incision and draining could reduce S. aureus colonization and chances of recurrent infection, the researchers conducted a prospective evaluation that included 383 children with S. aureus skin and soft tissue infection who needed incision and drainage, as well as children with S. aureus colonization in the anterior nares, axillar or inguinal folds at the time of baseline screening.
The researchers recorded the prescription of systemic antibiotics at point of care, and they then repeated sampling of bacteria for 357 children within 3 months (median 38 days; IQR: 22-50 days). Data were collected on recurring infections for up to 1 year.
Children with purulent skin and soft tissue infections who were prescribed guideline-recommended empiric antibiotics had a lesser chance of remaining colonized when follow-up sampling was conducted compared with children who did not receive antibiotics (adjusted HR 0.49, 95% CI 0.30, 0.79). These children were also less likely to have recurrent skin and soft tissue infections than those who did not receive antibiotics (aHR 0.57, 95% CI 0.34, 0.94).
Recurrent infection over 12 months was observed to be more plausible if the child remained colonized at repeat sampling (aHR 2.37,95% CI 1.69, 3.31). When prescribing antibiotics, clindamycin was more effective at eliminating S. aureus than trimethoprim-sulfamethoxazole (TMP-SMX) (44% vs. 57% remain colonized, P = .03). The antibiotic was also more effective at preventing recurrent skin and soft tissue infection (31% vs. 47%, P = .008)
“Using antibiotics judiciously to treat staph infections eliminates staph colonization and prevents more infection from occurring in the future,” Patrick G. Hogan, MPH, clinical research specialist at the Washington University School of Medicine, said in the release. “This reduces the overall burden of the staph germ on the environment and people, which results in less recurrence and, therefore, less antibiotic use.” – by Katherine Bortz
Disclosure: The authors report no financial disclosures.
Perspective
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C. Buddy Creech, MD, MPH
There are at least 3 major findings from this excellent paper by Stephanie Fritz and her colleagues in St. Louis. First, it has become clear over the last few years that treatment of skin abscesses beyond merely incision and drainage has short term benefits, as cure rates are higher in those who receive antibiotics. Data from this study suggest that there are also long-term benefits by reducing the risk for recurrent infections, which occur in 20-30% of patients depending on age and other risk factors.
Second, the mechanism for reduced risk of infection appears to be due to changes in colonization (or at the very least colonization density) in patients treated with systemic antibiotics; however, not all antibiotics are created equal. In multiple studies, clindamycin appears to be superior to TMP/SMX in reducing the risk of subsequent infection, though tolerability and gastrointestinal-related side effects are typically higher for clindamycin.
Finally, this work showcases the utility of leveraging ongoing clinical trials to test hypotheses that may be outside of the scope of the trials themselves. The result of these supplemental research questions is a greater understanding of the pathogenesis of recurrent S. aureus skin and soft tissue infections, leading to optimization of treatment strategies and ultimately prevention of disease.
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