Tag Archives: trimethoprim/sulfamethoxazole

Clindamycin or Trimethoprim-Sulfamethoxazole for skin infections?

Posted on by

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.”

Sometimes more is not better

Posted on by

‘More is not better’ may be the case with trimethoprim/sulfamethoxazole (TMP/SMX) Pneumocystis prophylaxis (PCP) (J Pediatr 2014; 164: 389-92).  This study indicates that a single-day course of TMP/SMX prophylaxis is as effective as other regimens.

Design: Prospective survey of 20 centers with newly diagnosed cancer between 2009-2011.  This included 1093 with solid tumors and 1373 with leukemia/lymphoma.  55.6% received 3-day/week prophylaxis, 16.5% received 2-day/week regimen, and 27.9% received 1-day/week regimen (5-10 mg/kg/day into 2 doses).

Key result:

  • Incidence of PCP at 3 years was 0.09% overall.  The two cases occurred in the 2-day regimen (though both had withdrawn from treatment)

The authors note the need for PCP prophylaxis has been questioned for solid tumor patients.  However, the lack of PCP among the 439  children with leukemia/lymphoma indicates that a single day per week regimen is effective.

Bottomline: In GI/liver patients who need TMP/SMX prophylaxis, 1-day per week regimen is likely effective (as it is in leukemia/lymphoma patients).  One-day/week is easier and should help with compliance, which is the key to preventing PCP.