EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess

incomplete Journal Club Article

Talan DA et al.. "Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess". NEJM. 2016. 374(9):823-832.
PubMed Full text

Clinical Question

In settings with MRSA, does Trimethoprim-sulfamethoxazole treatment after Incision and drainage of an abscess result in a greater cure rate?

Conclusion

Trimethoprim–sulfamethoxazole treatment resulted in a higher cure rate among patients with a drained cutaneous abscess than placebo for abscess that are successfully drained.

Major Points

Methicillin-resistant Staphylococcus aureus (MRSA) is a well known cause of many abscesses in the ED being the most common cause of purulent skin and soft-tissue infections.^[1]^[2]^[3] Treatment for cutaneous abscesses has been incision and drainage with antibiotics generally reserved for those that also had associated cellulitis. This multicenter, double-blind, randomized Controlled Trial of 5 US EDs with >1200 patients challenges the traditional dogma of no antibiotics for simple small uncomplicated abscesses that can be drained. For abscess of median size, 2.5 x 2.0 x 1.5cm that underwent I&D and co-administration of 5 days of TMP/SMX, cure rates were 80.5% vs 73.6% with placebo and I&D.^[4]

Study Design

Multi-Center, Double-Blind RCT

Population

Patient Demographics

Inclusion Criteria

Age >12 years of age
Cutaneous lesion that was:
- Either suspected to be an abscess on the basis of physical examination or
- Confirmed via ultrasonography AND
- Found to have purulent material on after I&D proration
Abscess for less than 1 week
Size of at least 2.0 cm in diameter (measured from boarder to border)
Deemed to be eligible for outpatient treatment per the ED physician

Exclusion Criteria

Suspected osteomyelitis or septic arthritis
Diabetic foot, decubitus, or ischemic ulcer
Mammalian bite
IVDU
Long-term care residence
Incarceration
Immunodeficiency (i.e. ANC <500/mm3)
Immunosuppressive drugs
Active chemotherapy
Known AIDS
Creatinine clearance <50mL/min
Taking warfarin, phenytoin, or methotrexate
Pregnant or lactating

Interventions

Outcomes

Primary Outcome

Clinical cure of the abscess lesion at 'test of cure' visit 7-14 days after the end of the treatment period

Secondary Outcomes

Subgroup analysis

Criticisms & Further Discussion

External Links

Funding

References

↑ Maligner D et al. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department. N C Med J. 2008 Sep-Oct;69(5):351-4.
↑ Pickett A et al. Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department. Pediatr Emerg Care. 2009 Dec;25(12):831-4.
↑ Bradley W. Frazee et al. High Prevalence of Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin and Soft Tissue Infections http://dx.doi.org/10.1016/j.annemergmed.2004.10.011
↑ Talan DA et al.. "Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess". NEJM. 2016. 374(9):823-832. [EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess|Bactrim and I&D NEJM]]

Authors:

[1] Maligner D et al. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department. N C Med J. 2008 Sep-Oct;69(5):351-4.

[2] Pickett A et al. Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department. Pediatr Emerg Care. 2009 Dec;25(12):831-4.

[3] Bradley W. Frazee et al. High Prevalence of Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin and Soft Tissue Infections http://dx.doi.org/10.1016/j.annemergmed.2004.10.011

[4] Talan DA et al.. "Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess". NEJM. 2016. 374(9):823-832. [EBQ:TMP-SMX vs Placebo for Uncomplicated Skin Abscess|Bactrim and I&D NEJM]]

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