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Abscess management

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Abscess management

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Abscess management

  1. 1. POP THAT PIMPLE ROLE OF ANTIBIOTICS IN ABSCESS MANAGEMENT
  2. 2. • Systematic review 2007 • Studies from RCTs from 1977 and 1982. • Cohort studies from 2000’s • Conclusion Cure rates similar between I+D with antibiotics and I+D alone.
  3. 3. GUIDELINES Australian • eTG I+D alone. Flucloxacillin if cellulitis and systemic symptoms. USA • Clinical Practice Guidelines by the Infectious Diseases Society of America I+D is primary treatment. Antibiotics >5cm Cellulitis Systemic symptoms Immunosuppression
  4. 4. TALAN ET AL. • 2016 • USA, Multicentre RCT, Double blind • 1247 patients • High dose Bactrim (320/1600mg) BD for 7 days versus placebo. • Abscesses > 2cm in size. • Primary outcome was clinical cure at 7-14 days. • 45% found to be MRSA.
  5. 5. TALAN ET AL. Primary Outcome (ITT) • Bactrim: 80.5% • Placebo: 73.6% Secondary Outcomes • Subsequent surgical drainage: 3.4% (Bactrim) vs 8.6% (placebo) • Skin infections at new sites: 3.1% (Bactrim) vs 10.3% (placebo) • Infections in household members: 1.7% (Bactrim) vs 4.1% (placebo)
  6. 6. TALAN ET AL. Complications • GIT upset Bactrim 42% Placebo 37% • Treatment cessation due to adverse events Bactrim 1.9% Placebo 0.6% • No cases of C.Diff
  7. 7. Aim: Subgroup analysis for populations guidelines recommend using antibiotics in. • >5cm abscess • cellulitis • Systemic features • Immunosuppression (T2DM, CRF)
  8. 8. Cure rates higher in all groups treated with Bactrim. No major difference between • >5cm and <5cm abscess • cellulitis >5cm and <5cm diameter • Immunosuppression (T2DM, CRF)
  9. 9. Greatest benefit in • Subjective symptoms of fevers (16.9%) • Hx of MRSA (22.9%) • MRSA grown in culture (20.7%) (Average improvement 12.2%)
  10. 10. DAUM ET AL. • 2017 USA, Multicentre RCT, Double blind • 786 patients (Paediatric and Adult) • 10 days of Bactrim (160/800mg) BD versus clindamycin (300mg) TDS versus placebo. • Abscesses <5cm in size. • Exclusions: obese, multiple lesions, systemically unwell, major comorbidities (T2DM) • 49% found to have MRSA.
  11. 11. DAUM ET AL. Primary outcome: clinical cure rates at 19-22 days • Clindamycin 83.1% • Bactrim 81.7% • Placebo 68.9%
  12. 12. DAUM ET AL. Treatment associated adverse events Clindamycin 21% Bactrim 11% Placebo 12% • No cases of C.Diff • 1 hypersensitivity reaction to Bactrim Fever, rash, thrombocytopenia, hepatitis (self limiting)
  13. 13. • Systematic review and meta-analysis of RCTs. • 2406 patients. • 4 studies.
  14. 14. Treatment failures • Antibiotics 7.7% Placebo 16.1% • NNT 13.5 Lesions at other sites • Antibiotics 6.2% Placebo 15.3% • NNT 11
  15. 15. Adverse events • Antibiotics 24.8% Placebo 22.2% • NNH 23
  16. 16. ISSUES • US studies only. • Significant amounts of overlying cellulitis in study populations. • Rare but serious drug side effects associated with Bactrim and clindamycin (C. Diff, SJS). • Changes to resistance patterns of Staph Aureus with widespread antibiotic use. • Which drug and what dose?

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