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
- 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
- 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)
- 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