Comparative effectiveness of antibiotic treatment strategies for pediatric skin and soft-tissue infections

Abstract

Objective: To compare the effectiveness of clindamycin, trimethoprim-sulfamethoxazole, and β-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 β-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 β-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 β-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 β-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 β-lactams.

Conclusions: Compared with clindamycin, use of trimethoprim-sulfamethoxazole or β-lactams was associated with increased risks of treatment failure and recurrence. Associations were stronger for those with a drainage procedure.

FIGURE 1

Cumulative hazards for SSTI recurrence for the drainage subgroup. SSTIs were determined on the basis of a visit with a specific ICD-9-CM code (Supplemental Table 4) and a filled prescription for an antibiotic within 2 days. Recurrence was defined as fulfilling the same criteria (including a new antibiotic) between 15 and 365 days after the incident event. Drainage was determined on the basis of CPT and ICD-9-CM procedure codes (Supplemental Table 4) representing incision and drainage. HRs were estimated in Cox proportional-hazard regression analyses with adjustment for year, age, gender, race/ethnicity, and diagnosis.

FIGURE 2

Cumulative hazards for SSTI recurrence for the no-drainage subgroup. SSTIs were determined on the basis of a visit with a specific ICD-9-CM code (Supplemental Table 4) and a filled prescription for an antibiotic within 2 days. Recurrence was defined as fulfilling the same criteria (including a new antibiotic) between 15 and 365 days after the incident event. Drainage was determined on the basis of CPT and ICD-9-CM procedure codes (Supplemental Table 4) representing incision and drainage. HRs were estimated in Cox proportional-hazard regression analyses with adjustment for year, age, gender, race/ethnicity, and diagnosis.