Dear Editor,
Co-trimoxazole for skin and soft tissue infections
not responding to conventional oral antibiotics in
Hong Kong
Patients with skin and soft tissue infections which do
not respond to conventional oral antibiotic treatments are
often referred to the hospital's Emergency Department. These
commonly include cases of wound infection and cellulitis,
and patients are often hospitalised for intravenous antibiotics.
However, when there are no clear signs of systemic infection,
especially in immunocompetent or healthy patients, admission
may not be necessary if an appropriate trial of antibiotic
regime adjustment is given.1,2,3 Although co-trimoxazole
would be regarded as an outdated antibiotic by most Hong
Kong doctors, there is in fact strong evidence to support its
use in this particular clinical context.
From my working experience in the Emergency
Department, the patients with wound infection and cellulitis
have typically been on antibiotics such as amoxicillin /
clavulanate and/or cloxacillin, or cephalexin to cover against
staphylococcus aureus and beta-haemolytic streptococci.
When the patient may not show the usual features of Systemic
Inflammatory Response Syndrome (based on temperature,
heart rate, respiratory rate, white cell count) admission
into hospital was usually not necessary.1,2,3 Poor response
to therapy may be because of antibiotic resistance due to
community-associated methicillin-resistant staphylococcus
aureus (CA-MRSA). International experts including those
from the Infectious Diseases Society of America currently
recommend co-trimoxazole as one of the antibiotics of choice
when empiric coverage of CA-MRSA is considered.1,2,3 In
Hong Kong, the incidence of CA-MRSA is rising, with a
study in 2009 showed that CA-MRSA was isolated from
13% of infected wounds and 17% of purulent cellulitis.4
Moreover, local data showed that CA-MRSA in Hong Kong
is also sensitive to co-trimoxazole.5 At the author's hospital,
data from our Antibiogram, January 1, 2016 - December
31, 2016 prepared by the hospital's Infection Control Team,
99% of staphylococcus aureus isolated from specimens from
different hospital units in 2016 (n=1542) were susceptible to
co-trimoxazole. By comparison, only 68% of these isolates
were susceptible to cloxacillin.
For skin and soft tissue infections, lack of response to
initial therapy should be followed by a collection of wound
swab for culture and sensitivity, and the addition of a trial
of co-trimoxazole for antibiotic therapy to cover against CA-MRSA.
Streptococcal coverage with penicillins or cephalexin
should be continued. The patient should be closely followed
up to monitor for signs of systemic infection, and should
be admitted if clinically indicated. If co-trimoxazole is
contraindicated, doxycycline and minocycline are alternative
choices of oral antibiotics for CA-MRSA, with minocycline use being supported by local data.1,2,3,5 This approach can be
utilised, not only by emergency department physicians, but
also by primary care practitioners in the outpatient setting.
For proven cases of CA-MRSA infection, decolonisation
therapy is recommended.
Cautiously however, before prescription of co-trimoxazole, authoritative references should be consulted on
drug interactions, adverse effects and contraindications. Of
particular note, co-trimoxazole may cause hyperkalaemia,
especially for the renal impaired and elderly patient,
and it may potentiate the effect of other concomitant
medications that may also cause hyperkalaemia. It may
induce hypoglycaemia, and the drug is also contraindicated
in pregnancy. Therefore, co-trimoxazole should not be used
indiscriminately as a first-line antibiotic for uncomplicated
skin and soft tissue infection. A recent randomised clinical
trial showed that adding co-trimoxazole to cephalexin in
uncomplicated cellulitis did not increase overall clinical cure
rate, so it may not help every patient and further research
may be needed to ascertain its effectiveness.6 In Hong Kong,
Filipino ethnicity appears to be a risk factor for CA-MRSA
and hence empiric addition of co-trimoxazole may be justified
in such cases.4
Yours sincerely,
Stewart SW Chan, MBBS (Syd), FRCSEd, FRCEM,
FHKAM (Emergency Medicine)
Senior Medical Officer, Accident & Emergency Department,
Prince of Wales Hospital
Email: stewart_chan@hotmail.com / csw912@ha.org.hk
References
- Raff AB, Kroshinsky D. Cellulitis: A review. JAMA. 2016;316(3):325-337.
doi: 10.1001/jama.2016.8825.
- Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the
diagnosis and management of skin and soft tissue infections: 2014 update
by the infectious diseases society of America. Clinical Infectious Diseases.
2014;59:e10-e52. doi: 10.1093/cid/ciu444.
- Sartelli M, Malangoni MA, May AK, et al. World society of emergency
surgery (WSES) guidelines for management of skin and soft tissue
infections. World Journal of Emergency Surgery. 2014;9:57. Available from:
https://wjes.biomedcentral.com/articles/10.1186/1749-7922-9-57. [Accessed
2017 October 6.]
- Ho PL, Chuang SK, Choi YF, et al. Community-associated methicillinresistant
Staphylococcus aureus skin and soft tissue infections in Hong
Kong. Hong Kong Med J. 2009;15(Supp 9): S9-11.
- Ho PL, Wong SSY. Reducing bacterial resistance with IMPACT -
Interhospital multi-disciplinary programme on antimicrobial chemotherapy,
4th edition. Hong Kong SAR: Centre for Health Protection; 2012. Available
from: http://www.chp.gov.hk/files/pdf/reducing_bacterial_resistance_with_
impact.pdf. [Accessed 2017 October 6.]
- Moran GJ, Krishnadasan A, Mower WR, et al. Effect of cephalexin plus
trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of
uncomplicated cellulitis. A randomised clinical trial. JAMA. 2017;317:2088-
2096. doi: 10.1001/jama.2017.5653. PMID:28535235
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