Uncomplicated Skin and Soft Tissue Infections Caused by Community-Associated Methicillin-Resistant Staphylococcus Aureus

Condition(s) targeted: Methicillin-Resistant S.Aureus

Intervention: Clindamycin (Drug); Trimethoprim-sulfamethoxazole (TS) (Drug); Placebo (Drug)

Phase: Phase 2/Phase 3

Status: Recruiting

Sponsored by: National Institute of Allergy and Infectious Diseases (NIAID)

Overall contact:
Henry Chambers, Phone: (415) 206-5437

The purpose of this clinical trial is to evaluate 2 different antibiotics, drugs that fight bacteria, [clindamycin (CLINDA) and trimethoprim-sulfamethoxazole (TMP-SMX)] and wound care for the outpatient management of uncomplicated skin and soft tissue infections (uSSTIs) in children and adults. The study will occur in areas where community associated methicillin-resistant Staphylococcus (S.) aureus are common. S. aureus is a type of bacteria. A total of 1310 volunteers, greater than or equal to 6 months of age, non-immunocompromised, with uSSTIs (in particular abscess and/or cellulitis) will be enrolled in this study. Subjects will be treated with one of the following: CLINDA, TMP-SMX, or placebo (contains no medication). Volunteers will be grouped based on the presence of cellulitis or abscess, whether the abscess can be surgically drained, and its size. The subject participation duration for this study is about 6 weeks.

Official title: Randomized, Double-Blind Trial of Clindamycin, Trimethoprim-Sulfamethoxazole, or Placebo for Uncomplicated Skin and Soft Tissue Infections Caused by Community-Associated Methicillin-Resistant Staphylococcus Aureus

Study design: Treatment, Randomized, Double Blind (Subject, Investigator), Placebo Control, Parallel Assignment, Safety/Efficacy Study

Primary outcome: Clinical cure, defined as absence of clinical failure.

Secondary outcome:

Efficacy outcome: clinical cure.

Safety outcomes: adverse events; and adverse events that are treatment limiting.

Detailed description: Clinical practice in the treatment of community-onset skin and soft tissue infections (SSTI) has not kept pace with the emergence of Methicillin-Resistant Staphylococcus aureus (MRSA) in the community. This clinical trial will evaluate Clindamycin (CLINDA) and Trimethoprim-Sulfamethoxazole (TMP-SMX) and wound care for the outpatient management of uSSTI in 3 metropolitan areas, Chicago, Los Angeles, and San Francisco, cities with high prevalence of community acquired (CA)-MRSA. This is a phase IIb multicenter, stratified, randomized, double-blind trial in which enrolled subjects with abscess or cellulitis will be treated with either CLINDA, TMP-SMX, or placebo. Participants will include 1310 non-immunocompromised out-patients age 6 months to 85 years with SSTIs not requiring hospital admission. Subjects will undergo a screening/baseline evaluation, including determination of presence and size of abscess and/or presence of cellulitis. Subjects will then be randomized to receive treatment with either CLINDA, TMP-SMX, or placebo depending on whether they have: a larger drainable abscess, defined as greater than 5 cm in diameter in adults and as greater than 3 cm in diameter for ages 6-11 months, greater than 4 cm for ages 1-8 years, and greater than 5 cm for age 9 years and older; a limited drainable abscess, defined as less than or equal to 5 cm for adults and as less than or equal to 3 cm for ages 6-11 months, less than or equal to 4 cm for ages 1-8 years, and less than or equal to 5 cm for age 9 years and older; or cellulitis or erysipelas only. If the diameter of the abscess greater than 5 cm (smaller for children depending on age) or 2 or more sites of skin infection are present the subject will be randomized (1: 1) to 10 days of therapy with TMP-SMX or CLINDA. If the diameter of the abscess less than or equal to 5 cm (smaller for children depending on age) then the subject will be randomized (1: 1:1) to TMP-SMX, CLINDA or placebo for 10 days. Subjects with cellulitis or erysipelas only will be randomized (1: 1) to TMP-SMX or CLINDA for 10 days. Subjects will be provided study drug, instructed in its use, and scheduled for 4 follow-up visits including: wound check (24-48h after enrollment); end of therapy (48h after completion of therapy); test of cure (7-10 days after completion of therapy); and a final visit at one month after completion of therapy. The primary objectives of this study are: to compare the cure rate of CLINDA to that of TMP-SMX for the treatment of patients with cellulitis or larger abscess at the Test of Cure (TOC) visit and to compare the cure rate of CLINDA, TMP-SMX, and placebo, each in conjunction with surgical drainage for the treatment of subjects with limited abscess at the TOC visit. The primary efficacy endpoint for the trial is clinical cure, which is the absence of clinical failure. The secondary objectives are: to estimate the cure rates of CLINDA and of TMP-SMX, and their difference, for limited abscess, cellulitis, or larger abscess: at the End of Treatment (EOT) visit, one month follow-up (OMFU) visit, in children and adults at the TOC visit; and for children versus adults at the TOC visit; to compare rates of adverse events and of adverse events that are treatment limiting between CLINDA and TMP-SMX for limited abscess, cellulitis, or larger abscess: at the TOC visit, EOT visit, and for children and adults separately at the TOC visit; and to estimate rates of adverse events and of adverse events that are treatment limiting for CLINDA and for TMP-SMX for limited abscess, cellulitis, or larger abscess for children, for adults, and the difference between children and adults. Secondary efficacy endpoints are: clinical cure at the EOT visit and clinical cure at the OMFU visit. Study duration will be for 3 years with subject participation duration equal to 6 weeks.

Minimum age: 6 Months. Maximum age: 85 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Age 6 months to 85 years.

- Able to complete the informed consent process or, if a minor, a parent or guardian

who is able to complete the informed consent process; an assent form also will be completed for children age 7 and older.

- Willing and able to complete the study protocol, study-related activities, and

visits.

- Diagnosis of uncomplicated skin and soft tissue infection (uSSTI), either cellulitis

(defined as an inflammation of skin and associated skin structures) or abscess (defined as a circumscribed collection of pus), evidenced by at least 2 of the following localized signs or symptoms on the skin for at least 24 hours:

Erythema Swelling or induration Local warmth Purulent drainage Tenderness to palpation or pain

- Able to take oral antibiotic therapy, either in pill or suspension form.

Exclusion Criteria:

- Hospital in-patient.

- Hospitalization within the prior 14 days.

- Residence in a long-term skilled nursing facility.

- Requirement for hospitalization for skin infection or other condition.

- Previous enrollment in this protocol.

- Participation in another clinical trial within the previous 30 days or plans to

enroll in another clinical trial during the study period.

- Superficial skin infection only, including: impetigo, ecthyma, folliculitis, or

infections that have a high cure rate after surgical incision alone (such as isolated furunculosis) or after topical or local measures.

- Unstable psychiatric or psychological condition rendering the subject unlikely to be

cooperative or to complete study requirements.

- Active drug or alcohol use or dependence that, in the opinion of the site

investigator, would interfere with the adherence or subject compliance with study requirements.

- Systolic blood pressure > 180 mm Hg

- Systolic blood pressure (SBP) less than an age-specific critical value:

Age 6 - 11 months: < 70 mm Hg Age 1 to 8 years: < 80 mm Hg Age 9 to 17 years: < 90 Age

greater than or equal to 18 years: < 90 mm Hg

- Heart rate less than 45 beats per minute (BPM).

- Heart rate greater than an age-specific critical value:

Age 6 - 11 months: > 140 beats BPM Age 1 to 8 years: > 120 BPM Age 9 to 17 years: > 120

BPM Age greater than or equal to 18 years: > 120 BPM.

- Oral temperature less than 35. 5 degrees C (95. 9 degrees F).

- Oral temperature (or equivalent rectal, tympanic membrane, axillary) greater than

age-specific critical value:

Age 6 - 11 months: > 38. 0 degrees C (100. 4 degrees F) Age 1 to 8 years: > 38. 5 degrees C

(101. 3 degrees F) Age 9 to 17 years: > 38. 5 degrees C (101. 3 degrees F) Age greater than or equal to 18 years: > 38. 5 degrees C (101. 3 degrees F).

- Human or animal bite in the past 30 days at the site of infection.

- Antimicrobial treatment within the prior 14 days.

- The following concomitant medications: warfarin, phenytoin, or methotrexate.

- Diagnosed or suspected disseminated or severe S. aureus or GAS infection, including

lymphangitic spread of skin infection, septicemia, bacteremia, pneumonia, endocarditis, osteomyelitis, septic arthritis, gangrene, necrotizing fasciitis, myositis, or other serious infections.

- Infection at an anatomical site skin requiring specialized management or specialized

antimicrobial therapy, including Periauricular or orbital infection Perirectal infection within 2 cm of the anus Suspected deep space infection of the hand or foot Genital infection

- Radiographic evidence or suspicion of gas in the tissue or foreign body infection

(note: radiography is not required for screening and can be performed at the discretion of the treating physician).

- Gastrointestinal symptoms such as nausea, vomiting, or diarrhea of a severity that

would preclude consumption of oral antibiotics.

- Hypersensitivity or history of allergic reaction to study drug.

- History of G6PD deficiency.

- Third trimester pregnancy: pregnant women must have gestational age estimated by an

objective means, e. g. ultrasound, fundal height, and women who are within 4 weeks of the third trimester of pregnancy, defined as week 27 of pregnancy, are not eligible.

- Severe or morbid obesity with a body mass index (BMI) greater than or equal to 35

kg/m^2.

- Complicated skin or soft tissue infection, such as Catheter or catheter site

infection within 30 days of placement Surgical site infection Known or suspected prosthetic device infection Suspected Gram-negative or anaerobic pathogen Unusual exposure history (e. g., underwater injury, fish-tank exposure, heavy soil exposure, etc) Infection at the site of an area of underlying skin disease such as chronic eczema, psoriasis, atopic dermatitis, or chronic venous stasis

- History of underlying immunocompromising condition or immunodeficiency, for example

Diabetes mellitus Chronic renal failure, creatinine clearance <30 ml/min Renal dialysis within the past 180 days HIV-positive with either CD4 count <200 or <4% CD4 in the past 180 days or HIV-positive and no documented CD4 count in the past 4 months Organ or bone marrow transplantation (ever), immunosuppressive therapy within the past 180 days, severe liver disease Other serious underlying disease, as determined by the treating physician or the investigator

Henry Chambers, Phone: (415) 206-5437

San Francisco General Hospital, San Francisco, California 94110, United States; Recruiting

Harbor-UCLA Medical Center, Torrance, California 90509, United States; Recruiting

University of Chicago, Chicago, Illinois 60637, United States; Recruiting

Starting date: April 2009
Ending date: July 2012
Last updated: October 15, 2009