{"id":8221,"date":"2016-10-29T18:06:43","date_gmt":"2016-10-29T22:06:43","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8221"},"modified":"2018-09-23T07:03:34","modified_gmt":"2018-09-23T11:03:34","slug":"antibiotics-small-abscesses-now-theres-answer","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/antibiotics-small-abscesses-now-theres-answer\/2016\/10\/29\/","title":{"rendered":"Are Antibiotics Useful for Small Skin Abscesses? Now There&#8217;s an Answer"},"content":{"rendered":"<div id=\"attachment_8222\" style=\"width: 252px\" class=\"wp-caption alignright\"><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2016\/10\/footprint-IDWeek.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-8222\" class=\" wp-image-8222\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2016\/10\/footprint-IDWeek.jpg\" alt=\"A &quot;few&quot; more steps is quite the understatement.\" width=\"242\" height=\"332\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2016\/10\/footprint-IDWeek.jpg 292w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2016\/10\/footprint-IDWeek-218x300.jpg 218w\" sizes=\"auto, (max-width: 242px) 100vw, 242px\" \/><\/a><p id=\"caption-attachment-8222\" class=\"wp-caption-text\">A &#8220;few&#8221; more steps is quite the understatement. And who chose that carpet?<\/p><\/div>\n<p>Let&#8217;s start with the clinical controversy, one that&#8217;s been bouncing around Emergency Rooms, outpatient practices, postgraduate courses, and medical journals for years. Specifically, are antibiotics helpful\u00a0for skin abscesses that are adequately drained?<\/p>\n<p>It&#8217;s still debated since of\u00a0course\u00a0most patients with this annoying problem will get better on their own provided the\u00a0drainage is adequate. What do the antibiotics add, if anything?<\/p>\n<p>Now,\u00a0thanks to a superb clinical trial presented this past week in New Orleans at the annual IDWeek Meeting, we have some answers.<\/p>\n<p>And though the study is important, there&#8217;s a good chance you don&#8217;t\u00a0know about it, even if you attended IDWeek. First, just like the last time this group presented results of a different trial on\u00a0<a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/clindamycin-vs-tmpsmx-for-soft-tissue-infections-a-clinical-trial-that-needs-some-marketing\/2013\/09\/13\/\" target=\"_blank\" rel=\"noopener\">at a national meeting<\/a>, the abstract presentation took place in front of a only a handful of meeting\u00a0participants.<\/p>\n<p>Second, even if you <em>wanted<\/em> to come see the presentation, you might have been stymied by the vast travel distances\u00a0inside the\u00a0New Orleans Convention Center, which must be one of the longest indoor spaces on the planet.\u00a0Safe to say that no one who attended this meeting finished a day with fewer than 10,000 steps, unless they brought along their hoverboards or Segways. Sometimes it felt like I was walking half the way to Baton Rouge.<\/p>\n<p>(For the record,\u00a0that first study ended up being\u00a0a <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1403789\" target=\"_blank\" rel=\"noopener\">major paper in the esteemed <em>New England Journal of Medicine<\/em>.<\/a>\u00a0Justice!)<\/p>\n<p>Anyway, here are some of the details of this <a href=\"http:\/\/ofid.oxfordjournals.org\/content\/3\/suppl_1\/1684.full?sid=e647dbfc-fc02-4d0f-86ca-67e866eea164\" target=\"_blank\" rel=\"noopener\">new study:<\/a><\/p>\n<ul>\n<li>Adults and children with small skin abscesses were eligible provided they weren&#8217;t immunocompromised, diabetic, or systemically ill.<\/li>\n<li>They all underwent abscess drainage and cultures.<\/li>\n<li>Participants were randomized 1:1:1 to receive TMP\/SMX, or clindamycin, or placebo for ten days. <em>(Glad they followed the <strong><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/how-to-figure-out-the-length-of-antibiotic-therapy\/2010\/10\/22\/\" target=\"_blank\" rel=\"noopener\">Golden Rule.<\/a><\/strong>)<\/em><\/li>\n<li>786 subjects enrolled (505 adults and 281 children) at several sites around the country.<\/li>\n<li>67% had positive cultures for <em>Staph aureus<\/em>; 74% of these\u00a0isolates were MRSA.<\/li>\n<li>At a 10-day post-therapy visit, cure of infection was seen in 83.1% and 81.7% of clindamycin\u00a0and TMP\/SMX treated patients respectively &#8212; both significantly better than placebo (68.9%).<\/li>\n<li>TMP\/SMX was better tolerated than clindamycin, with adverse event rates of 11% (TMP\/SMX) and 22% (clindamycin). Placebo was 12.5% (guess that&#8217;s the\u00a0&#8220;nocebo&#8221; effect). There were\u00a0no cases of C diff\u00a0or\u00a0severe rashes.<\/li>\n<li>Clindamycin-treated patients had fewer relapses than those receiving TMP\/SMX.<\/li>\n<\/ul>\n<p>The droll presenter, Dr. Robert Daum, and the senior author, Dr. Chip Chambers, made a couple of\u00a0other interesting observations. First,\u00a0if the\u00a0culture grew\u00a0a <em>Staph aureus <\/em>resistant to clindamycin, responses were reduced. The good news is that this resistance was observed\u00a0in only around 5% of isolates, a much lower percentage\u00a0than typically seen\u00a0in <em>Staph aureus<\/em> from hospitalized patients.<\/p>\n<p>Second, if cultures were\u00a0negative for staph, response rates were similar between all three treatment arms &#8212; meaning you could potentially\u00a0<em>stop<\/em> antibiotics in select patients based on culture results\u00a0(though important caveat, this strategy wasn&#8217;t tested).<\/p>\n<p>The results of this study add to a <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1507476?af=R&amp;rss=currentIssue#t=article\" target=\"_blank\" rel=\"noopener\">growing body of evidence<\/a> that antibiotics do in fact improve outcomes even for drained skin abscesses, swinging the pendulum further back in the direction of using them for this indication. Whether you and\u00a0your patient think that this net 10-15% increase chance of cure\u00a0is worth\u00a0the risks of antibiotics will probably depend on the case &#8212;\u00a0but at least now we have the data to make an informed decision.<\/p>\n<p>And boy, do my feet hurt.<\/p>\n<p><iframe loading=\"lazy\" title=\"EDWIN STARR - 25 MILES (CLIP FROM UPBEAT TV SHOW 1969)\" width=\"500\" height=\"375\" src=\"https:\/\/www.youtube.com\/embed\/ndw9u0_nBSk?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Let&#8217;s start with the clinical controversy, one that&#8217;s been bouncing around Emergency Rooms, outpatient practices, postgraduate courses, and medical journals for years. Specifically, are antibiotics helpful\u00a0for skin abscesses that are adequately drained? It&#8217;s still debated since of\u00a0course\u00a0most patients with this annoying problem will get better on their own provided the\u00a0drainage is adequate. What do the [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[1142,189,1143,947],"class_list":["post-8221","post","type-post","status-publish","format-standard","hentry","category-health-care","tag-abscess","tag-clindamycin","tag-idweek","tag-trimethoprimsulfamethoxazole"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8221","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8221"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8221\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8221"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8221"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8221"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}