Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections

Abstract

WHAT'S KNOWN ON THIS SUBJECT:The burden of pediatric skin and soft-tissue infections (SSTIs) is increasing, largely as a result of the widespread community emergence of methicillin-resistant Staphylococcus aureus (MRSA). Optimal antimicrobial management strategies for SSTIs in the era of communityassociated MRSA remain unclear. WHAT THIS STUDY ADDS:These findings, from a cohort of nearly 50 000 children with incident SSTIs, bring into question the use of trimethoprim-sulfamethoxazole for treatment of purulent SSTIs in community-associated MRSA-prevalent regions in which clindamycin resistance remains low. ␤-Lactams, however, may still be effective for nonpurulent SSTIs. abstract OBJECTIVE: To compare the effectiveness of clindamycin, trimethoprimsulfamethoxazole, and ␤-lactams for the treatment of pediatric skin and soft-tissue infections (SSTIs). METHODS: A retrospective cohort of children 0 to 17 years of age who were enrolled in Tennessee Medicaid, experienced an incident SSTI between 2004 and 2007, and received treatment with clindamycin (reference), trimethoprim-sulfamethoxazole, or a ␤-lactam was created. Outcomes included treatment failure and recurrence, defined as an SSTI within 14 days and between 15 and 365 days after the incident SSTI, respectively. Adjusted models stratified according to drainage status were used to estimate the risk of treatment failure and time to recurrence. RESULTS: Among the 6407 children who underwent drainage, there were 568 treatment failures (8.9%) and 994 recurrences (22.8%). The adjusted odds ratios for treatment failure were 1.92 (95% confidence interval [CI]: 1.49 -2.47) for trimethoprim-sulfamethoxazole and 2.23 (95% CI: 1.71-2.90) for ␤-lactams. The adjusted hazard ratios for recurrence were 1.26 (95% CI: 1.06 -1.49) for trimethoprim-sulfamethoxazole and 1.42 (95% CI: 1.19 -1.69) for ␤-lactams. Among the 41 094 children without a drainage procedure, there were 2435 treatment failures (5.9%) and 5436 recurrences (18.2%). The adjusted odds ratios for treatment failure were 1.67 (95% CI: 1.44 -1.95) for trimethoprim-sulfamethoxazole and 1.22 (95% CI: 1.06 -1.41) for ␤-lactams; the adjusted hazard ratios for recurrence were 1.30 (95% CI: 1.18 -1.44) for trimethoprim-sulfamethoxazole and 1.08 (95% CI: 0.99 -1.18) for ␤-lactams. CONCLUSIONS: Compared with clindamycin, use of trimethoprimsulfamethoxazole or ␤-lactams was associated with increased risks of treatment failure and recurrence. Associations were stronger for those with a drainage procedure. Pediatrics 2011;128:e479-e487 AUTHORS:

Outcomes After Skin and Soft Tissue Infection in Infants 90 Days Old or Younger

“…Despite this limitation, we found a similar treatment failure rate as the 6% to 9% rate found in 1 outpatient study of patients aged 0 to 17 with SSTI in Tennessee. 12 This comparative effectiveness study identified use of trimethoprim-sulfamethoxazole or b-lactams, particularly if a drainage procedure was performed, as an association with increased risk of treatment failure compared with use of clindamycin. 12 To our knowledge, no previous studies have assessed risks or associated factors for treatment failure in neonates/young infants presenting to the hospital with SSTI.…”

“…In our study, we elected to define treatment "failure" as new hospital encounters, on the basis that these natural or anticipated changes might ideally be done in the outpatient setting and that a revisit to the hospital might reflect a "failure" of the system. Previous studies have used similar definitions for treatment "failure" (ie, a new outpatient SSTI claim plus an antibiotic prescription or drainage procedure or new inpatient hospitalization with discharge diagnosis code of SSTI within 14 days of the initial SSTI 12 ). In some cases, the treatment failures found in our study may have been "appropriate" (such as if sedation was needed for a drainage procedure), but in other cases, it may reflect failure of the system to organize appropriate outpatient follow-up.…”

“…Similar to previously published studies on SSTIs, our study used ICD-9 codes to identify potential subjects. 1,2,12,13 See online Supplemental Appendix 1 for inclusion and exclusion ICD-9 diagnosis, procedure, and Current Procedural Terminology codes. To minimize misclassification, we reviewed the charts of all included patients with primary ICD-9 for SSTI as well as a random sample of 20% of the patients with a secondary ICD-9 for SSTI.…”

Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections

“…Lanyard cards included information on optimal antibiotic duration and suggested treatment regimens according to evidence available at the time of the project. 6,7 We specifically designed lanyard cards to be attached to personnel badges for ease of use in the clinical setting (Fig 2).…”

Second Annual Meeting of the International Society of Pediatric Wound Care

“…The spectra of the types of wounds in children are much different than the common distal extremity wound and pressure ulcers over bony prominences seen in adult patients. In pediatric wound care, the variety of wounds encountered include more soft tissue infections, [8][9][10] device-related pressure ulcers, 11,12 ostomy and gastrostomy tube issues, congenital skin diseases, congenital malformations, and traumatic injuries that can encompass large areas of the body. [13][14][15] We also have less tolerance for expecting children to endure pain, and so frequently many pediatric procedures are done with some level of anesthesia, which in an adult patient would be done with minimal anesthetic and at the bedside.…”