Comparison of Cephalexin Versus Clindamycin for Empiric Treatment of Suspected CA-MRSA Skin Infections

Condition(s) targeted: Staphylococcal Infection; Abscess; Staphylococcal Skin Infection; Folliculitis

Intervention: clindamycin (Drug); cephalexin (Drug)

Phase: Phase 4

Status: Recruiting

Sponsored by: Johns Hopkins University

Official(s) and/or principal investigator(s):
Aaron E Chen, MD, Principal Investigator, Affiliation: Johns Hopkins University

Overall contact:
Aaron E Chen, MD, Phone: 410-955-6143, Email: achen33@jhmi.edu

The purpose of this study is to help define the role of antibiotics in the treatment of pediatric skin infections caused by CA-MRSA. We hypothesize that treatment with cephalexin, a penicillin-like antibiotic to which CA-MRSA would be expected to be resistant, does not result in poorer outcomes than treatment with clindamycin, an antibiotic to which CA-MRSA is most often susceptible.

Official title: Comparison of Cephalexin Versus Clindamycin in the Empiric, Outpatient Treatment of Suspected Staphylococcal Cutaneous Infections in the Era of Community-Acquired Methicillin-Resistant Staphylococcus Aureus (CA-MRSA)

Study design: Treatment, Randomized, Double Blind (Subject, Caregiver), Active Control, Parallel Assignment, Efficacy Study

Primary outcome: Clinical improvement at the 48-72 hour clinical follow-up

Secondary outcome:

Clinical improvement at 7 days

Time to clinical improvement

Time to resolution of disease

Treatment failures

Need for subsequent hospitalization

Need for subsequent procedure

Detailed description: Community-associated methicillin resistant Staphylococcus Aureus (CA-MRSA) infections have increased significantly over the past decade. Nearly every major region of the country has reported infections with this organism, with some areas reporting a prevalence as high as 80%. Epidemiologic evidence points to the emergence of a new strain of MRSA within the community, with unique genetic and clinical characteristics that differentiate it from traditional hospital-associated MRSA (HA-MRSA). Unlike HA-MRSA, these CA-MRSA are often susceptible in vitro to multiple antibiotic classes (other than penicillins and cephalosporins), and often cause significant, deep-seated abscesses in healthy individuals without any known risk factors for healthcare contact. Prior to awareness of this disease, many clinicians were using penicillin and cephalosporin antibiotics for empiric treatment of cutaneous abscesses, yet widespread treatment failures in the face of increasing CA-MRSA infections did NOT occur. During a one-year retrospective study in pediatric patients at our institution, we found that nearly 50% of CA-MRSA abscesses were treated with "inappropriate" antibiotics by susceptibility profiles without any significant adverse outcomes. Many clinicians are now confronted with the dilemma of whether to change empiric antibiotic therapy to other classes to which CA-MRSA would be expected to be susceptible; the most common choices including clindamycin, TMP-SMX, or vancomycin. Unfortunately, each of these antibiotics has problems of its own in terms of increased cost, poor palatability of pediatric liquid formulation, poorer side effect profile, or necessity of IV infusion, and at this time the optimal, empiric antibiotic treatment for presumed CA-MRSA skin and soft tissue infections is unclear.

The purpose of this study is to help define the role of antibiotics in the treatment of pediatric skin infections caused by CA-MRSA. We hypothesize that treatment with cephalexin, a penicillin-like antibiotic to which CA-MRSA would be expected to be resistant, does not result in poorer outcomes than treatment with clindamycin, an antibiotic to which CA-MRSA is most often susceptible.

Minimum age: 6 Months. Maximum age: 18 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Children between the ages of 6 months and 18 years of age (inclusive)

- Suspected purulent staphylococcal skin or soft tissue infection

- No hospitalization within the previous 14 days

- Must have reliable means of follow-up contact (e. g. working phone)

- Outpatient management in the judgement of treating physician

Exclusion Criteria:

- Hospitalization on initial visit

- Voluntary withdrawal by the treating physician in order to dictate the antibiotic

being used

- Patients with a history of hypersensitivity to or intolerance of cephalexin (or other

beta lactams) or clindamycin.

- Patients with altered immunity (inherited or acquired)

- Patients with skin infections related to surgical wounds or hardware.

- Patients currently on antibiotic therapy

Aaron E Chen, MD, Phone: 410-955-6143, Email: achen33@jhmi.edu

Johns Hopkins University, Baltimore, Maryland 21287, United States; Recruiting
Aaron E Chen, MD, Phone: 410-955-6143, Email: achen33@jhmi.edu
Aaron E Chen, MD, Principal Investigator

Expert Summary of Recommendations for management of MRSA in the community

Starting date: September 2006
Ending date: December 2008
Last updated: May 6, 2008