5-Minute Journal

Today’s 5 minute journal was performed by the great resident, Dr. Bill McDowell, who absolutely crushed it.

Article Title

NEJM, 2017

I think this is a great article to review as we see abscesses frequently, and it somewhat becomes humdrum in the ED. Abscesses are also fraught with debate on who should receive antibiotics vs. I+D alone. The main takeaways from this article are below.

Abscess Background
— Historically, I+D by itself has an approximate 84% cure rate
— Many small previous studies showed no difference in cure rates of I+D alone vs. I+D with antibiotics
— One prior large study (Talan et al, 2016) found superior cure rates with Bactrim/I+D vs. placebo/I+D (80.5% vs. 73.6% cure rate).

Article Summary
Clinical Question:  Do antibiotics with anti-MRSA activity improve cure rates for abscesses when given following I+D?
Study Type:  Multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial (superiority design)
—  Study Groups:  10-day courses of Clindamycin vs. Bactrim vs. Placebo (following standard I+D)
—  Inclusion Criteria:  single abscess <5cm diameter, age>6 months, 1 day of 2 or more symptoms (erythema, swelling/induration, local warmth, purulent drainage, tenderness)
—  Exclusion Criteria:  BMI>40, immunocompromised (including diabetes, chronic renal failure), immunosuppresive therapy, SIRS criteria present, Temp>38.5C, human/animal bite, site requiring specialist (genitalia, perirectal, hand), anti-staphylococcus antibiotic in past 14 days, requires admission, resident of long-term care facility, major surgery in past 12 months
— Primary Outcome Being Tested:  Clinical Cure. “Lack of Clinical cure” was defined as:  continued signs/symptoms, occurrence of skin infection at new body site, reoccurrence at original site, inability to take entire course of antibiotic secondary to adverse side effects, hospitalization related to infection, or unplanned surgical treatment of infection
Study Population:  786 patients (36% peds). 343 patients fully adherent to antibiotic 10-day course. Average surrounding area of erythema 27.4 cm²  (~5×5 cm)
— Results:
—  Cure rates:  clindamycin: 83.1%, Bactrim: 81.7%, Placebo: 68.9%
(Statistical significance for antibiotics vs. placebo). No statistical
signifance between bactrim vs. clindamycin
—  Most failures due to new lesion at other site or use of rescue
medication- especially in placebo group
—  Rates of Diarrhea:  Clindamycin 21.9%, Bactrim 11.1%, Placebo 12.5%
—  Study population had large surrounding erythema suggesting large
percentage of co-associated cellulitis

—  Antibiotics have a clinically significant higher cure rate compared to placebo. However, this study population had a relatively large surrounding area of erythema, which makes it unclear whether the antibiotics were treating the abscess itself or the co-associated cellulitis. Furthermore, it appears the advantage of antibiotic use in these patients was in preventing occurrence of an abscess at a separate site, which suggests the antibiotics main function was in clearing MRSA recidivism in this patient population vs. the actual treatment of the original skin infection.
—  Although there was no statistical difference in cure rates between Bactrim and Clindamycin, it does appear to be advantageous to prescribe Bactrim vs. Clindamycin as was associated with fewer side effects–mainly rates of diarrhea (Clinda 21.9% vs. Bactrim 11.1%)
—  Abscess treatment has evolved greatly over the last decade with several studies performed during this time. RebelEM provides a great summary of this research (RebelEM Abscesses). I also love this review because it refers to some amazing work by our own RUSH staff including Dr. Gottlieb and Dr. Hallock as well as our always consulted pharm team including Josh DeMott and Gary Peska (Annals of EM Link)

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