Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess

David A. Talan, William R. Mower, Anusha Krishnadasan, Fredrick M. Abrahamian, Frank Lovecchio, David J. Karras, Mark T. Steele, Richard E. Rothman, Rebecca Hoagland, Gregory J. Moran

Research output: Contribution to journalArticle

Abstract

Background U.S. emergency department visits for cutaneous abscess have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). The role of antibiotics for patients with a drained abscess is unclear. Methods We conducted a randomized trial at five U.S. emergency departments to determine whether trimethoprim-sulfamethoxazole (at doses of 320 mg and 1600 mg, respectively, twice daily, for 7 days) would be superior to placebo in outpatients older than 12 years of age who had an uncomplicated abscess that was being treated with drainage. The primary outcome was clinical cure of the abscess, assessed 7 to 14 days after the end of the treatment period. Results The median age of the participants was 35 years (range, 14 to 73); 45.3% of the participants had wound cultures that were positive for MRSA. In the modified intention-totreat population, clinical cure of the abscess occurred in 507 of 630 participants (80.5%) in the trimethoprim-sulfamethoxazole group versus 454 of 617 participants (73.6%) in the placebo group (difference, 6.9 percentage points; 95% confidence interval [CI], 2.1 to 11.7; P=0.005). In the per-protocol population, clinical cure occurred in 487 of 524 participants (92.9%) in the trimethoprim-sulfamethoxazole group versus 457 of 533 participants (85.7%) in the placebo group (difference, 7.2 percentage points; 95% CI, 3.2 to 11.2; P<0.001). Trimethoprim-sulfamethoxazole was superior to placebo with respect to most secondary outcomes in the per-protocol population, resulting in lower rates of subsequent surgical drainage procedures (3.4% vs. 8.6%; difference,-5.2 percentage points; 95% CI,-8.2 to-2.2), skin infections at new sites (3.1% vs. 10.3%; difference,-7.2 percentage points; 95% CI,-10.4 to-4.1), and infections in household members (1.7% vs. 4.1%; difference,-2.4 percentage points; 95% CI,-4.6 to-0.2) 7 to 14 days after the treatment period. Trimethoprim-sulfamethoxazole was associated with slightly more gastrointestinal side effects (mostly mild) than placebo. At 7 to 14 days after the treatment period, invasive infections had developed in 2 of 524 participants (0.4%) in the trimethoprim-sulfamethoxazole group and in 2 of 533 participants (0.4%) in the placebo group; at 42 to 56 days after the treatment period, an invasive infection had developed in 1 participant (0.2%) in the trimethoprim-sulfamethoxazole group. Conclusions In settings in which MRSA was prevalent, trimethoprim-sulfamethoxazole treatment resulted in a higher cure rate among patients with a drained cutaneous abscess than placebo.

Original languageEnglish (US)
Pages (from-to)823-832
Number of pages10
JournalNew England Journal of Medicine
Volume374
Issue number9
DOIs
StatePublished - Mar 3 2016

ASJC Scopus subject areas

  • Medicine(all)

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    Talan, D. A., Mower, W. R., Krishnadasan, A., Abrahamian, F. M., Lovecchio, F., Karras, D. J., Steele, M. T., Rothman, R. E., Hoagland, R., & Moran, G. J. (2016). Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. New England Journal of Medicine, 374(9), 823-832. https://doi.org/10.1056/NEJMoa1507476