It turns out that both clindamycin and trimethoprim-sulfamethoxazole are good choices for uncomplicated skin infections (NEJM 2015; 372: 1093-103).
In this prospective, randomized trial with 524 patients (children and adults), outpatients with uncomplicated skin infections (cellulitis and abscesses) were treated with either clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) for 10 days. Abscesses underwent initial incision and drainage. Both groups had a similar rate of MRSA: 31.8% and 31.9% respectively.
- The proportion of patients cured was similar in both groups. Among those with adequate followup, 89.5% of clindamycin group were cured compared with 88.2% of TMP-SMX.
- Adverse effects were similar as well. Diarrhea was the most common adverse event and occurred in 9.7% and 10.1% respectively.
Limitations: trial excluded patients with serious coexisting conditions, involved only outpatients, and followup was for 1 month.
The associated editorial (pg 1164-65) suggests that the design of the study may obscure the likelihood that TMP-SMX might be preferred for empirical treatment of skin abscess (if I&D alone is insufficient) and that clindamycin might be more effective for cellulitis.
Take-home point: With the changes in skin infections, including MRSA, this trial indicates that both clindamycin and TMP-SMX are good options for treating uncomplicated skin infections.
Commentary from NEJM Journal Watch, by Larry Baddour, Chair, Division of Infectious Diseases at Mayo Clinic College of Medicine: “For most patients, however, β-lactam antibiotics with activity against β-hemolytic streptococci and S. aureus (e.g., cephalexin or dicloxacillin) remain the first-line empirical treatment options for nonpurulent cellulitis. Epidemiologic and host factors, however, should continue to influence this decision.”