There was no benefit to the addition of coverage for MRSA, supporting the traditional recommendation to use a beta-lactam alone. With fewer physicians choosing Infectious Diseases as a specialty, I wonder how many people will even recognize this in the future.Īnother randomized, double-blind trial compared cephalexin to that plus TMP-SMX for treating uncomplicated cellulitis. I am concerned that a trend towards treating everything by algorithm or “what if it could be MRSA?” will result in more mistreatment of this common skin infection. It does not respond as well to TMP-SMX or vancomycin. This is caused by Strep and is generally treated with penicillin. This is distinctive, with a sharply demarcated border and skin that is thickened (indurated) and often bright red. One clinically recognizable type of cellulitis is erysipelas. TMP-SMX was not used alone for strep infections if uncertain about whether an infection was due to Staph or Strep, some used TMP-SMX in combination with amoxicillin.Īnother cellulitis study found that 73% of hospitalized patients had beta-hemolytic streptococci as the causative agent this had a 97% response with a beta-lactam.Įrysipelas (Photo By BSIP/UIG Via Getty Images) Typical choices would be penicillin, or either dicloxacillin or cephalexin, which adds coverage for “regular” or methicillin-susceptible Staph, though some use clindamycin. Recommendations from both the Infectious Diseases Society of America (IDSA) and UpToDate are to use a beta-lactam type drug, i.e., a penicillin or cephalosporin. While not stated explicitly, the authors imply that either clindamycin or TMP-SMX are perhaps the best choices for uncomplicated cellulitis, as this covers MRSA and worked well overall.īased on literature and my 30+ years of experience as an infectious diseases practitioner, I have several concerns regarding this shift in focus and treatment, treating everyone for MRSA.įirst, nonpurulent cellulitis, meaning one where there is no abscess or drainage to culture), is most commonly caused by Streptococci, not Staph. aureus was isolated in 41.4% 12 % of these isolates were resistant to clindamycin and one was TMP-SMX resistant. Cultures could be obtained from the abscesses and S. Abscesses occurred in 30.5%, and 16% had both. Half of the patients had cellulitis, an infection of the skin and soft tissue. The authors also used a 10-day course of treatment, when expert recommendations are encouraging 5-7 days treatment to try to reduce risks to patients. It also encourages the “just in case” type of response, rather than prescribers actually thinking about what kind of bacterial infection the patient might have. I think this is a bad idea-it fuels the escalating use of broader spectrum antibiotics with more side effects, at a time when antibiotic development is languishing. Surprisingly, both worked equally well in this 524 patient study, curing about 89% of outpatients with uncomplicated skin infections cellulitis and abscesses, so the authors appear to encourage use of one of these drugs because they are better at treating MRSA than are currently recommended antibiotics. A new study in the New England Journal of Medicine on treatment of skin infections compares treatment with trimethoprim sulfamethoxazole (TMP-SMX, Bactrim or Septra) or clindamycin.
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