Re: Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline
Vermandere et al. have submitted rapid recommendations on antibiotic use after incision and drainage for uncomplicated skin abscesses. These recommendations are mostly based on the meta-analysis and more specifically recent RCT studies such as Daum et al., who reported the benefit of clindamycin or TMP-SMX in conjunction with incision and drainage on short-term outcomes among patients with uncomplicated cutaneous abscesses, particularly those caused by Staphylococcus aureus.
First, the primary outcome of most of the studies was a subjective lack of clinical cure assessed by a nurse without adjusting for repeated measures or any random effect in the statistic analysis. No hygiene status was done which constitutes a confounder factor. TMP-SMX and particularly clindamycin can induce potential side effects which could challenge the blindness of the treatment.
Secondly, the rationale of these studies is defended by the high proportion of CA-MRSA with Panton-Valentine leukocidin (PVL) in the USA; it has to be remembered and it makes extrapolation of the results not possible everywhere. Indeed, in the most recent study, 49.4% of isolated bacteria are CA-MRSA which is specific to USA ecology and there was no mention of PVL having been done.
Thirdly, the duration of the treatment is too long in the current context of antimicrobial resistance and the strong need to limit antibiotic exposure, especially when surgical treatment seems to be sufficient to treat such infections[4,5]. Even if there is no more Clostridium difficile infections in these studies, TMP-SMX and clindamycin have an important ecologic impact of intestinal anaerobic flora and microbiome[6-8].
No potential conflict of interest relevant to this letter are reported.
1 Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018;:k243. doi:10.1136/bmj.k243
2 Wang W, Chen W, Liu Y, et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ Open 2018;8:e020991. doi:10.1136/bmjopen-2017-020991
3 Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med 2017;376:2545-55. doi:10.1056/NEJMoa1607033
4 Schmitz GR, Bruner D, Pitotti R, et al. Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection. Ann Emerg Med 2010;56:283-7. doi:10.1016/j.annemergmed.2010.03.002
5 Rajendran PM, Young D, Maurer T, et al. Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection. Antimicrob Agents Chemother 2007;51:4044-8. doi:10.1128/AAC.00377-07
6 Card RM, Mafura M, Hunt T, et al. Impact of Ciprofloxacin and Clindamycin Administration on Gram-Negative Bacteria Isolated from Healthy Volunteers and Characterization of the Resistance Genes They Harbor. Antimicrob Agents Chemother 2015;59:4410-6. doi:10.1128/AAC.00068-15
7 Yang J-J, Wang J-T, Cheng A, et al. Impact of Broad-spectrum Antimicrobial Treatment on the Ecology of Intestinal Flora. J Microbiol Immunol Infect Published Online First: June 2017. doi:10.1016/j.jmii.2016.12.009
8 Ferrer M, Méndez-García C, Rojo D, et al. Antibiotic use and microbiome function. Biochem Pharmacol 2017;134:114-26. doi:10.1016/j.bcp.2016.09.007
Competing interests: No competing interests