COMMENTARY

Comparable Results for Skin Infection Treatments

Graeme M. Lipper, MD

Disclosures

May 04, 2015

Clindamycin Versus Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Infections

Miller LG, Daum RS, Creech CB, et al
N Engl J Med. 2015;372:1093-103

Background

Community-acquired skin infections are most commonly caused by Staphylococcus aureus or Streptococcus pyogenes, pathogens that used to be predictably responsive to beta-lactam antibiotics and cephalosporins. Unfortunately, methicillin-resistant S aureus (MRSA) has become endemic in many regions, with MRSA accounting for 75% of S aureus isolates in some communities.[1,2] In this context, clindamycin and trimethoprim-sulfamethoxazole (TMP-SMX) have become the antibiotics of choice for treating uncomplicated skin infections—ie, infections without sepsis/bacteremia or deeper tissue involvement such as osteomyelitis. Both clindamycin and TMP-SMX are cost-effective, relatively well tolerated, and safe, but is one superior to the other?

To address this question, Miller and colleagues performed a large (N = 524), multicenter, randomized, double-blind clinical trial of clindamycin (n = 264) vs TMP-SMX (n = 260) for the treatment of uncomplicated skin infections. Of these patients, roughly 31% had an abscess, 53% had cellulitis, and 16% had mixed infections. S aureus was the most common pathogen cultured (41.4%), and an alarming 77% of these isolates were methicillin resistant.

As part of the study protocol, all abscesses were incised and drained, followed by treatment with 10 days of either clindamycin 300 mg three times daily or TMP-SMX (160 mg/800 mg) given as two single-strength tabs twice daily. The study's main outcome measure was clinical cure, assessed 7-10 days after completion of the antibiotic course. In addition, patients were monitored for adverse effects and assessed at 1-month follow-up.

The researchers observed comparable efficacy and safety in both antibiotic groups:

  • Cure rates in the intention-to-treat populations were comparable in the clindamycin (80.3%) and TMP-SMX (77%) groups.

  • Overall adverse event rates were comparable with clindamycin (18.9%) and TMP-SMX (18.6%), with similar rates of the most common side effects: diarrhea, nausea, vomiting, pruritus, and rash.

  • Most patients were able to tolerate the full antibiotic courses, with statistically comparable discontinuation rates (8.3% vs 8.8%).

  • Cure rates at 1-month follow-up were comparable in both groups.

S aureus isolates in this study were more likely to be resistant to clindamycin than TMP-SMX (5.2% vs 0.2%). Although this did not affect overall response rates, clindamycin-resistant isolates were predictably more resistant to clindamycin than sensitive isolates (73.3% cure rate vs 91.7% cure rate, respectively).

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