Antibiotics + Abscesses: To I&D and Beyond!

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    Antibiotics + Abscesses: To I&D and Beyond!

    So you’ve I&D’d that abscess, there’s no surrounding cellulitis you’re ready to Treat em’ and Street em’ but the patient asks: “Can I have some antibiotics, please? And maybe a sandwich?” [you probably make the face above right?]

    Well what a recent study by Talan et al (2016) found is that the answer to that question (not the sandwich part) just got a little bit more complicated. They conducted an RCT at 5 EDs. They enrolled patients w/ abscesses >2cm who were healthy or with certain comorbidities (ex DM, IVDU…).  They gave TMP-SMX to the treatment arm at a dose of 320mg/1600mg, 2x/d for 7d. 

    They found the treatment group (TMP-SMX) had significantly better outcomes with abscess cure rates of 93% vs 86% in the placebo group (NNT=14).

    • Cure was defined as resolution of abscess by day 14-21 at test-of-cure assessment. 
    • 45.3% of patients had would cultures positive for MRSA.
    • They saw significance in 2/3 of their study groups: (1) per-protocol (2) modified intention-to-treat group; they did not find significance in the (3) FDA guidance early end-point population who took at least 1 dose and had a 48-72hr followup

    In addition to greater cure rates, the treatment group had: (1) lower recurrent infections (2) fewer subsequent I&Ds (3) fewer hospitalizations (4) less pain (5) less household members with abscesses

    Interestingly the placebo group had 36% GI upset….vs 43% in treatment group

    No significant skin reactions were seen in the treatment group and no cases of Cdiff

    Limitations:

    • Only 65% of study population was 100% adherent to antibiotics
    • Some abscesses in the placebo group had surrounding cellulitis and they still got better…?!
    • TMP-SMX can have multiple medication interactions and side effects

    Consider wound culture in those patients who: [adapted from PEMBLOG]

    • You are thinking about starting on antibiotics
    • Failed tx on antibiotics
    • Has signs of severe local infection or systemic illness
    • There is a concern for a regional outbreak

    RECAP:

    • Consider the wait and see approach by giving certain at risk patients  a prescription and telling them to fill it only if their abscess is not improving after 48hrs
    • Consider TMP-SMX for people with recurrent abscesses
    • This is the first RCT that shows significant improvement of abscesses w/ use of antibiotics since MRSA became a thing…(I’m not sure how long it really has been a thing)

     

    Sources:

    • Orman, R. & Rezaie,S. Abscess + Antibiotics = Better Outcome? 2016. EMRAP. https://www.emrap.org/episode/abscess/abscess
    • Talan, David A., et al. “Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess.” New England Journal of Medicine 374.9 (2016): 823-832
    • Sobolewski, B. Briefs: Do we need antibiotics after I&D of a cutaneous abscess? http://pemcincinnati.com/blog/briefs-need-antibiotics-id-cutaneous-abscess-re-post/#iLightbox[gallery3675]/null
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