Clindamycin or Trimethoprim-Sulfamethoxazole for skin infections?

It turns out that both clindamycin and trimethoprim-sulfamethoxazole are good choices for uncomplicated skin infections (NEJM 2015; 372: 1093-103).

In this prospective, randomized trial with 524 patients (children and adults), outpatients with uncomplicated skin infections (cellulitis and abscesses) were treated with either clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) for 10 days.  Abscesses underwent initial incision and drainage.  Both groups had a similar rate of MRSA: 31.8% and 31.9% respectively.

Key findings:

  • The proportion of patients cured was similar in both groups.  Among those with adequate followup, 89.5% of clindamycin group were cured compared with 88.2% of TMP-SMX.
  • Adverse effects were similar as well.  Diarrhea was the most common adverse event and occurred in 9.7% and 10.1% respectively.

Limitations: trial excluded patients with serious coexisting conditions, involved only outpatients, and followup was for 1 month.

The associated editorial (pg 1164-65) suggests that the design of the study may obscure the likelihood that TMP-SMX might be preferred for empirical treatment of skin abscess (if I&D alone is insufficient) and that clindamycin might be more effective for cellulitis.

Take-home point: With the changes in skin infections, including MRSA, this trial indicates that both clindamycin and TMP-SMX are good options for treating uncomplicated skin infections.

Commentary from NEJM Journal Watch, by Larry Baddour, Chair, Division of Infectious Diseases at Mayo Clinic College of Medicine:  “For most patients, however, β-lactam antibiotics with activity against β-hemolytic streptococci and S. aureus (e.g., cephalexin or dicloxacillin) remain the first-line empirical treatment options for nonpurulent cellulitis. Epidemiologic and host factors, however, should continue to influence this decision.”

Long-term Outcomes with Pediatric PEG Placement

As noted about a week ago in this blog, gastrostomy tube (gtube) placement in children is much different from gtube placement in adults.

A retrospective study from Boston Children’s followed 138 patients who had PEG tube placed between 1999-2000 (JPGN 2013; 57: 663-67).  The median followup was approximately 5 years.

Results:

  • Median time to elective tube removal was 10.2 years.
  • ~50% of patients continued with gastrostomy tube 10 years after placement.
  • 11% (n=15) had at least 1 major complication related to gastrostomy placement.  Major complication was defined as any unplanned adverse events requiring hospitalization, surgery (eg. fundoplication) or interventional radiology (eg. gastrojejunal tube placement). Most major complications occurred during the first 6-12 months following placement with the most common being cellulitis (n=10).
  • 18% of the cohort died during the 10-year study period because of non-gastrostomy-related issues.  No deaths were attributed to gastrostomy tube placement.

Bottomline: The need for gastrostomy tube placement is associated with frequent comorbidities.  A significant number of patients undergoing gastrostomy tube placement experience major complications.

Also noted:

JPGN 2013; 57: 659-62. This prospective study of 69 patients showed that early reintroduction of feedings after gastrostomy placement, 4 hours postoperatively, was safe and compared favorably to those fed 12 hours postoperatively.  Early feedings were associated with hospital duration, on average, of 6.7 hours. At this center, prophylactic antibiotics were not administered without apparent increase in infections.

JPGN 2013; 57: 668-72. This retrospective study of 77 children with feeding disorders showed that inpatient behavioral interventions are effective in transitioning children from gastrostomy tube feeding to oral feeding.

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