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Practice Rapid Recommendations

Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k243 (Published 06 February 2018) Cite this as: BMJ 2018;360:k243

Population

This recommendation applies to almost all patients with skin abscesses: People with skin abscesses Children and adults Unknown or unconfirmed pathogen(s) Smaller and larger abscesses Emergency and primary care settings However the recommendation is not applicable to patients with: Evidence of systemic illness (sepsis) Pustules and papules Deep tissue infections Immunocompromising conditions Hidradenitis suppurativa Patients who do not undergo incision and drainage

Comparison 1

or No antibiotics Antibiotics Incision and drainage plus trimethoprim and sulfamethoxazoleor clindamycin Incision and drainage alone No antibiotics Antibiotics + or CLI TMP SMX

We suggest TMP-SMX or clindamycin plus incision and drainage rather than incision and drainage alone. Discuss both options with each patient. All Applies to Click fordetails Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours no antibiotics Favours antibiotics Evidence quality Events per 1000 people Outcomes (1 month) No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

47 fewer Treatment failure High More 43 90

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics with activity against MRSA reduce the risk of treatment failure

63 fewer Recurrence Moderate More 66 129

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency Borderline Publication bias No serious concerns Antibiotics probably reduce the risk of early abscess recurrence

Invasive infections Moderate More 4 4 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of invasive infections
Evidence quality Events per 1000 people Outcomes (3–4 days)

68 fewer Pain (tenderness) Moderate More 491 559

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably reduce pain during treatment
Evidence quality Events per 1000 people Side effects (TMP-SMX)

Gastrointestinal side effects Moderate More 106 21 fewer 85

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of gastrointestinal side effects

11 fewer 24 Nausea Moderate More 35

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of nausea

No important difference Diarrhoea Moderate More 62 67

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of diarrhoea
Evidence quality Events per 1000 people Side effects (clindamycin)

Gastrointestinal side effects Moderate More 185 95 fewer 90

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of gastrointestinal side effects

Nausea Moderate More 23 24 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably no important difference in the risk of nausea

Diarrhoea Moderate More 162 96 fewer 67

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Antibiotics probably increase the risk of diarrhoea
See all outcomes (TMP-SMX)
See all outcomes (Clindamycin)
Different people probably place different values on the expected consequences (both desirable and undesirable) of taking antibiotics. Different individuals are likely to choose different treatment options. Shared decision making is needed to elicit these values and preferences. Preferences and values Antibiotic resistance Antibiotic use increases antibiotic resistance in the community and in recurrent infections in the individual. However, the impact of a single course of antibiotics is very uncertain. Key practical issues No antibiotics Antibiotics No practical issues Typically taken 2–3 times daily, for 5–10 days

Comparison 2

For patients who have chosen to initiate antibiotics: First and second generation cephalosporins or Trimethoprim andsulfamethoxazole or Clindamycin Cephalosporins Trimethoprim and sulfamethoxazoleor clindamycin Cephalosporins CEPH or CLI TMP SMX

We recommend trimethoprim and sulfamethoxazole or clindamycin over cephalosporins. Those initiating antibiotics Applies to Click fordetails Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours TMP-SMX Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 280 162 fewer 119

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns TMP-SMX probably reduces the risk of treatment failure
See all outcomes
Favours clindamycin Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 280 171 fewer 109

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Clindamycin probably reduces the risk of treatment failure
See all outcomes
No antibiotics Favours cephalosporins Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure Moderate More 295 180 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Cephalosporins probably do not reduce the risk of treatment failure
See all outcomes
This strong recommendation applies to the most common situation where the risk of methicillin-resistant Staphylococcal aureus is more than 10%. MRSA The basis for this recommendation is that cephalosporins are probably less effective than TMP-SMX and clindamycin and they may not be more effective than placebo. Evidence interpretation Adverse effects Adverse effects differ between antibiotics. Key practical issues Trimethoprim and sulfamethoxazole Cephalosporins 2 pills, 2 times per day Typically less expensive Clindamycin 2 pills, 3 times per day Typically more expensive 1 pill 2-4 times per day Typically more expensive

Comparison 3

or Clindamycin Trimethoprim andsulfamethoxazole Clindamycin Trimethoprim and sulfamethoxazole For patients who have chosen to initiate antibiotics: CLI TMP SMX

We suggest trimethoprim and sulfamethoxazole over clindamycin. Discuss with patients in shared decision making. Those initiating antibiotics Click fordetails Applies to Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours clindamycin Favours TMP-SMX Evidence quality Events per 1000 people 1 month No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Treatment failure High More 119 109 No important difference

Risk of Bias No serious concerns Imprecision Borderline Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is no important difference in treatment failure

Early recurrence Low More 135 67 fewer 68

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns TMP-SMX may result in higher risk of early abscess recurrence

Diarrhoea High More 162 109 fewer 53

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns TMP-SMX has a lower risk of diarrhoea

Nausea Moderate More 43 23 No important difference

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns There is probably not an important difference in risk of nausea
See all outcomes
Different people probably place different values on the expected consequences (both desirable and undesirable) of taking antibiotics. Different individuals are likely to choose different treatment options. Shared decision making is needed to elicit these values and preferences. Preferences and values Antibiotic resistance Consider local resistance patterns when choosing the antibiotic as susceptibility patterns candiffer substantially. Key practical issues Clindamycin Trimethoprim and sulfamethoxazole 2 pills, 3 times per day Typically more expensive 2 pills, 2 times per day Typically less expensive

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Rapid Response:

Re: Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline

Vermandere et al.[1] have submitted rapid recommendations on antibiotic use after incision and drainage for uncomplicated skin abscesses. These recommendations are mostly based on the meta-analysis[2] and more specifically recent RCT studies such as Daum et al.[3], 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[3], 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

01 March 2018
Michael THY
MD
François-Xavier Lescure
Infectious diseases department, APHP, Hôpital Bichat-Claude Bernard, Paris, France
46 Rue Henri Huchard, 75877 Paris