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Abstract & Commentary
Cephalexin vs. Clindamycin for Pediatric Skin Infections Perhaps Drainage Is All That's Needed
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine, is Associate Editor for Infectious Disease Alert.
Dr. Winslow is a speaker for Cubist Pharmaceuticals and GSK, and is a consultant for Siemens Diagnostics.
Synopsis: Two hundred patients from 6 months to 18 years of age with uncomplicated skin and soft tissue infections (SSTIs) were randomly assigned to cephalexin (Keflex) vs. clindamycin. Spontaneous drainage or a drainage procedure was performed in 97% of patients. By 48-72 hours, 94% of patients in the cephalexin arm and 97% of patients in the clindamycin arm were improved. By day 7 all patients had improved.
Source: Chen AE, et al. Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections. Pediatrics 2011;127;e573-e580.
Two hundred patients from 6 months to 18 years of age with uncomplicated purulent SSTIs not requiring hospitalization were enrolled from 2006 through 2009. The infections included abscesses (with or without surrounding cellulitis), furuncles, or carbuncles. Patients were randomized to 7 days of cephalexin vs. clindamycin. Primary endpoints included clinical improvement at 48-72 hours and at 7 days. Cultures were obtained and isolates were tested for antimicrobial susceptibility, pulsed-field gel electrophoresis (PFGE) type, and Panton-Valentine leukocidin (PVL) production. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 69% of patients. Most of these were USA300 strains by PFGE typing, were positive for PVL, and were clindamycin-susceptible (91%). Nineteen percent grew methicillin-susceptible S. aureus (MSSA), 8% grew other organisms, and 5% were sterile. Spontaneous drainage occurred or patients underwent a drainage procedure in 97% of cases. Improvement by 48-72 hours occurred in 94% of cephalexin-treated patients and in 97% of clindamycin-treated patients. By day 7 all patients had improved with complete resolution demonstrated in 97% of cephalexin-treated patients and in 94% of clindamycin-treated patients. Fever and age < 1 year (but not initial erythema > 5 cm) were associated with early treatment failures in both antibiotic treatment groups. Four patients required hospitalization after enrollment, but in only two cases was this due to worsening of their initial infection. No serious adverse events related to study treatment were encountered. One 13-month-old child developed mild diarrhea with stool positive for Clostridium difficile toxin C. difficile toxin.
This large randomized trial performed in Baltimore is an important addition to the medical literature. The study illustrates a number of important points including the demonstration that two-thirds of SSTIs in inner city children in an East Coast U.S. city were due to MRSA. The study, most importantly, emphasizes the teaching point that the most important element of successful treatment of uncomplicated SSTIs is adequate drainage and that antimicrobials play a secondary role in their management. The essentially equivalent outcomes between clindamycin and what is essentially a placebo vs. MRSA (cephalexin), suggests that antimicrobials should be withheld in most cases of uncomplicated SSTIs as long as appropriate drainage and wound care is performed. Future, larger studies may determine whether the addition of an effective antibiotic may reduce the risk of recurrences or of transmission to close contacts, including family members.