Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis

Abstract

ObjectiveTo assess the impact of adjunctive antibiotic therapy on uncomplicated skin abscesses.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov.Study selectionA BMJ Rapid Recommendation panel provided input on design, important outcomes and the interpretation of the results. Eligible randomised controlled trials (RCTs) included a comparison of antibiotics against no antibiotics or a comparison of different antibiotics in patients with uncomplicated skin abscesses, and reported outcomes prespecified by the linked guideline panel.Review methodsReviewers independently screened abstracts and full texts for eligibility, assessed risk of bias and extracted data. We performed random-effects meta-analyses that compared antibiotics with no antibiotics, along with a limited number of prespecified subgroup hypotheses. We also performed network meta-analysis with a Bayesian framework to compare effects of different antibiotics. Quality of evidence was assessed with The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsFourteen RCTs including 4198 patients proved eligible. Compared with no antibiotics, antibiotics probably lower the risk of treatment failure (OR 0.58, 95% CI 0.37 to 0.90; low quality), recurrence within 1 month (OR 0.48, 95% CI 0.30 to 0.77; moderate quality), hospitalisation (OR 0.55, 95% CI 0.32 to 0.94; moderate quality) and late recurrence (OR 0.64, 95% CI 0.48 to 0.85; moderate quality). However, relative to no use, antibiotics probably increase the risk of gastrointestinal side effects (trimethoprim and sulfamethoxazole (TMP-SMX): OR 1.28, 95% CI 1.04 to 1.58; moderate quality; clindamycin: OR 2.29, 95% CI 1.35 to 3.88; high quality) and diarrhoea (clindamycin: OR 2.71, 95% CI 1.50 to 4.89; high quality). Cephalosporins did not reduce the risk of treatment failure compared with placebo (moderate quality).ConclusionsIn patients with uncomplicated skin abscesses, moderate-to-high quality evidence suggests TMP-SMX or clindamycin confer a modest benefit for several important outcomes, but this is offset by a similar risk of adverse effects. Clindamycin has a substantially higher risk of diarrhoea than TMP-SMX. Cephalosporins are probably not effective.

Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline

“…They requested a systematic review on the benefits and harms of different antibiotics to inform the recommendation. 15 The panel then met online to discuss the evidence and to formulate specific recommendations. As with all BMJ Rapid Recommendations, no panel member had financial conflicts of interest; intellectual and professional conflicts were minimised and managed (see appendix 1 on bmj.com).…”

“…To inform the recommendations, the guideline panel requested a systematic review of randomised controlled trials (RCTs) on the effects of adjuvant antibiotic therapy compared with no antibiotic therapy in addition to incision and drainage in patients with uncomplicated skin abscesses. 15 …”

“…Explicit descriptions of abscess definitions, for each trial, were summarised in the accompanying systematic review (table C of appendix 2). 15 The largest trial specifically focused on small abscesses (all <5 cm diameter and about half ≤2 cm) in patients who had no signs of systemic infection. 5 The RCTs included participants with skin abscesses anywhere on the body.…”

Optimal antimicrobial duration for common bacterial infections

“…Incision and drainage is the primary therapeutic modality for soft tissue abscesses. A recently published systematic review found that for uncomplicated abscesses, adjunctive antibiotic therapy provides a modest benefit in terms of treatment success and prevention of recurrence, 26 but this needs to be balanced against an increased risk of adverse events. Antibiotic courses ranged from 3-14 days and no recommendation on duration was made.…”

“…Antibiotic courses ranged from 3-14 days and no recommendation on duration was made. 26 A randomised controlled trial conducted in the remote Australian setting showed that short-course oral trimethoprim/sulfamethoxazole for 3-5 days is effective for impetigo, and equivalent to intramuscular benzathine penicillin. 27…”