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Associate Clinical Professor, Residency Program Director, Prime-LC, University of California-Irvine, Orange, California; Department of Family Medicine, University of California-Irvine, Orange, California
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As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
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Associate Clinical Professor, Residency Program Director, Prime-LC, University of California-Irvine, Orange, California; Department of Family Medicine, University of California-Irvine, Orange, California
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The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has changed the way clinicians care for patients in the United States as well as epidemiologic trends in skin and soft-tissue infections (SSTIs) itself. Hersh and colleagues evaluated these issues in a study published in the July 28, 2008, issue of the Archives of Internal Medicine. They found that the overall number of healthcare visits for SSTIs increased by 50% between 1997 and 2005, and this increase was most profound among black patients, patients younger than 18 years, and in the South. The use of medications used to treat MRSA increased from 7% at baseline to 28% in 2005, and this change was most pronounced in prescriptions from emergency departments.
When MRSA might account for more than 70% of all staphylococcal infections in some areas of the United States, what types of antibiotics provide superior results? The current analysis of antibiotics for the treatment of SSTIs among children seeks answers to this question.
Antibiotics vary in efficacy for pediatric SSTIs, according to the results of a retrospective cohort study reported online August 15 in Pediatrics.
"The burden of pediatric ...SSTIs is increasing, largely as a result of the widespread community emergence of methicillin-resistant ...MRSA," write Derek J. Williams, MD, MPH, from the Department of Pediatrics, School of Medicine and Monroe Carell Jr Children's Hospital at Vanderbilt University in Nashville, Tennessee, and colleagues. "Optimal antimicrobial management strategies for SSTIs in the era of community-associated MRSA remain unclear."
The goal of the study was to compare the efficacy of clindamycin (used as the reference standard), trimethoprim-sulfamethoxazole, and β-lactams for the treatment of pediatric SSTIs among children from birth to age 17 years who were enrolled in Tennessee Medicaid and had an incident SSTI between 2004 and 2007. The main study endpoints were treatment failure, defined as an SSTI within 14 days after the incident SSTI, and recurrence, defined as an SSTI occurring between 15 and 365 days. The risk for treatment failure and time to recurrence were estimated from adjusted models stratified on the basis of drainage status.
Treatment failures occurred in 568 (8.9%) of the 6407 children who underwent drainage, and recurrences in 994 (22.8%). For trimethoprim-sulfamethoxazole, the adjusted odds ratio (OR) for treatment failure was 1.92 (95% confidence interval [CI], 1.49 - 2.47); for recurrence, it was 1.26 (95% CI, 1.06 - 1.49). For β-lactams, the adjusted ORs were 2.23 (95% CI, 1.71 - 2.90) and 1.42 (95% CI, 1.19 - 1.69), respectively.
There were 2435 treatment failures (5.9%) and 5436 recurrences (18.2%) among the 41,094 children who did not undergo a drainage procedure. For treatment failure, the adjusted ORs were 1.67 (95% CI, 1.44 - 1.95) for trimethoprim-sulfamethoxazole and 1.22 (95% CI, 1.06 - 1.41) for β-lactams. For recurrence, the adjusted hazard ratios were 1.30 (95% CI, 1.18 - 1.44) for trimethoprim-sulfamethoxazole and 1.08 (95% CI, 0.99 - 1.18) for β-lactams.
"Compared with clindamycin, use of trimethoprim-sulfamethoxazole or β-lactams was associated with increased risks of treatment failure and recurrence," the study authors write. "Associations were stronger for those with a drainage procedure."
Limitations of this study include residual confounding, the lack of microbiologic data, and potential misclassification of antibiotic exposure and outcomes.
"These findings, from a cohort of nearly 50 000 children with incident SSTIs, bring into question the use of trimethoprim-sulfamethoxazole for treatment of purulent SSTIs in community-associated MRSA–prevalent regions in which clindamycin resistance remains low," the study authors conclude. "β-lactams, however, may still be effective for nonpurulent SSTIs."
The Agency for Healthcare Research and Quality supported this study in part. The study authors have disclosed no relevant financial relationships.
Pediatrics. Published online August 15, 2011.
Related Link
The Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children are available in full text online.
