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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: April 1, 2015
Expiration Date: April, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237U2

Last week 695 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 220 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Clindamycin and Trimethoprim-Sulfamethoxazole may have Similar Cure Rates in Patients with Uncomplicated Skin Infections

Reference: N Engl J Med 2015 Mar 19;372(12):1093 (level 2 [mid-level] evidence)

Skin infections are one of the most common types of infection worldwide, affecting persons of all ages and geographies (J Invest Dermatol 2014 Jun;134(6):1527). The incidence of abscesses and cellulitis appears to be increasing in the United States, where methicillin-resistant Staphylococcus aureus (MRSA) has been identified as the leading cause of skin abscesses, furuncles, and carbuncles (Arch Intern Med 2008 Jul 28;168(14):1585, BMC Infect Dis 2013 May 30;13(1):252). Suspected community-acquired MRSA is often treated with clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX, also known as co-trimoxazole), but certain strains of MRSA may have inducible clindamycin resistance. The potential for inducible resistance may influence some clinicians to prefer TMP-SMX for potential MRSA infections. In addition, clindamycin  has a relatively higher cost and increased risk of C. difficile infection, which along with local resistance patterns may all be factors in clinical decision making (J Fam Pract 2013 Nov;62(11):624, J Antimicrob Chemother 2013 Sep;68(9):1951). A recent randomized trial compared clindamycin 150 mg 3 times daily vs. TMP-SMX 160mg/800 mg twice daily for 10 days in 524 patients (mean age 27 years) with uncomplicated skin infections including cellulitis, abscesses > 5 cm in diameter, or both.

Of the 524 patients enrolled, 29.6% were children. The presenting infection included cellulitis in 53.4%, abscess in 30.5%, and a mixed infection defined as ≥ 1 abscess plus 1 cellulitis lesion in 15.6%. All abscesses had incision and drainage before administration of antibiotics. Cultures were prepared from samples taken from 56.5% of patients and S. aureus was isolated in 73.3% of cultures (77% of which were identified as MRSA). Overall, there was no significant difference in the clinical cure rate between days 7 and 10 of treatment comparing clindamycin vs. TMP-SMX, with clinical cure in 80.3% of patients with clindamycin and 77.7% of patients with TMP-SMX. In a subgroup analysis of patients with cellulitis without abscess, clindamycin was associated with a cure rate of 80.9% compared to 76.4% with TMP-SMX (not significant). There were also no significant differences in the cure rate at 7-10 days for patients with abscess, the overall clinical cure rate at 1 month, or adverse events.

The results of this trial suggest that clindamycin and TMP-SMX appear equally effective for treating uncomplicated skin infections in adults and children. Previous studies have suggested, however, that systemic antibiotics after incision and drainage of uncomplicated skin abscesses may not increase the clinical cure rate (Emerg Med J 2013 May 18 early online), thus many patients in this trial may have achieved clinical cure without antibiotics. In fact, the Infectious Disease Society of America (IDSA) recommends incision and drainage with complete evacuation of all purulent material as primary therapy for skin abscesses and only recommends systemic antibiotics for patients with an impaired immune system or signs of a systemic inflammatory response (Clin Infect Dis. 2014 Jul 15;59(2):e10). IDSA also recommends antimicrobial agents active against streptococci as first line treatment for patients with cellulitis, unless patients have risk factors for MRSA or symptoms of systemic inflammatory response syndrome, as streptococcal species seem to be the most common cause of cellulitis (Medicine (Baltimore) 2010 Jul;89(4):217, Clin Infect Dis 2008 Mar 15;46(6):855). The subgroup analysis of patients presenting with cellulitis without abscess suggest clindamycin might have a slightly higher clinical cure rate compared to TMP-SMX in this population, but this subgroup comparison is likely underpowered to detect statistically significant differences.

For more information, see the Skin abscesses, furuncles, and carbuncles and Cellulitis topics in DynaMed.

Quick Access to Clinical Answers with the DynaMed App

DynaMed users can access valuable evidence-based content anywhere with the updated DynaMed mobile app. The app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication, and easy access to the latest clinical content. It provides offline access and the ability to denote favorites, email topics, and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is complimentary for all personal and institutional DynaMed subscriptions. The app has also been designed for easy one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 9, 2015 Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

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