Journal Article: A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses

Authors: Daum RS, Miller LG, Immergluck L, et al. 

• A randomized, double-blind, placebo-controlled trial published in NEJM in 2017. It looked at whether giving antibiotics after incision and drainage improves outcomes in patients with small uncomplicated skin abscesses. 
• The study included 786 outpatient patients, both adults and children, who had a single skin abscess measuring 5 cm or less. All patients first underwent standard incision and drainage, which is considered the primary treatment for an abscess. 
• After drainage, patients were randomly assigned to receive either Clindamycin, Trimethoprim-sulfamethoxazole, or placebo for 10 days. 
• The main outcome they looked at was clinical cure 7- 10 days after completing treatment. The results showed that both antibiotics performed significantly better than placebo. The cure rate was 83.1% with clindamycin, 81.7% with TMP-SMX, and only 68.9% with placebo. This means that adding antibiotics improved cure rates by about 12–14% compared with drainage alone. 
• Another important finding was that there was no significant difference between clindamycin and TMP-SMX in initial cure rates, meaning both are effective options after drainage. 
• The study also looked at recurrence at 1 month, which I thought was especially relevant to my patient. Clindamycin had the lowest recurrence rate at 6.8%, compared with 13.5% for TMP-SMX and 12.4% for placebo, suggesting that clindamycin may be more effective at preventing recurrent or new abscess formation. 
• In terms of microbiology, Staphylococcus aureus was isolated in 67% of patients, and almost half of all patients had MRSA, which supports why empiric MRSA coverage is important in skin abscess management. 
• One of the main trade-offs discussed in the article was side effects.
  • Clindamycin had more adverse effects, particularly GI symptoms such as diarrhea, with side effects occurring in 21.9% of patients, compared with 11.1% with TMP-SMX. 
• This article directly relates to my patient because she was presented with a 2 cm draining gluteal abscess, which we further drained in office and sent for wound culture. She was started on Clindamycin which was selected due to its activity against Staphylococcus aureus, including possible community-acquired MRSA, which is a common cause of furuncles and skin abscesses. Clindamycin is considered acceptable for use during early pregnancy when clinically indicated.