Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial

Abstract

Importance: Emergency department visits for skin infections in the United States have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). For cellulitis without purulent drainage, β-hemolytic streptococci are presumed to be the predominant pathogens. It is unknown if antimicrobial regimens possessing in vitro MRSA activity provide improved outcomes compared with treatments lacking MRSA activity.

Objective: To determine whether cephalexin plus trimethoprim-sulfamethoxazole yields a higher clinical cure rate of uncomplicated cellulitis than cephalexin alone.

Design, setting, and participants: Multicenter, double-blind, randomized superiority trial in 5 US emergency departments among outpatients older than 12 years with cellulitis and no wound, purulent drainage, or abscess enrolled from April 2009 through June 2012. All participants had soft tissue ultrasound performed at the time of enrollment to exclude abscess. Final follow-up was August 2012.

Interventions: Cephalexin, 500 mg 4 times daily, plus trimethoprim-sulfamethoxazole, 320 mg/1600 mg twice daily, for 7 days (n = 248 participants) or cephalexin plus placebo for 7 days (n = 248 participants).

Main outcomes and measures: The primary outcome determined a priori in the per-protocol group was clinical cure, defined as absence of these clinical failure criteria at follow-up visits: fever; increase in erythema (>25%), swelling, or tenderness (days 3-4); no decrease in erythema, swelling, or tenderness (days 8-10); and more than minimal erythema, swelling, or tenderness (days 14-21). A clinically significant difference was defined as greater than 10%.

Results: Among 500 randomized participants, 496 (99%) were included in the modified intention-to-treat analysis and 411 (82.2%) in the per-protocol analysis (median age, 40 years [range, 15-78 years]; 58.4% male; 10.9% had diabetes). Median length and width of erythema were 13.0 cm and 10.0 cm. In the per-protocol population, clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 165 (85.5%) of 193 in the cephalexin group (difference, -2.0%; 95% CI, -9.7% to 5.7%; P = .50). In the modified intention-to-treat population, clinical cure occurred in 189 (76.2%) of 248 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 171 (69.0%) of 248 in the cephalexin group (difference, 7.3%; 95% CI, -1.0% to 15.5%; P = .07). Between-group adverse event rates and secondary outcomes through 7 to 9 weeks, including overnight hospitalization, recurrent skin infections, and similar infection in household contacts, did not differ significantly.

Conclusions and relevance: Among patients with uncomplicated cellulitis, the use of cephalexin plus trimethoprim-sulfamethoxazole compared to cephalexin alone did not result in higher rates of clinical resolution of cellulitis in the per-protocol analysis. However, because imprecision around the findings in the modified intention-to-treat analysis included a clinically important difference favoring cephalexin plus trimethoprim-sulfamethoxazole, further research may be needed.

Trial registration: clinicaltrials.gov Identifier: NCT00729937.

Figure 1.. Flow of Participants With Cellulitis Randomized to Treatment With Cephalexin Plus Trimethoprim-Sulfamethoxazole or Cephalexin Plus Placebo

See Table 1 for a description of the per-protocol, modified intention-to-treat (mITT-1 and mITT-2), and US Food and Drug Administration (FDA) guidance early end-point populations and outcome definitions. On-therapy, test-of-clinical-cure, and extended follow-up visits occurred on days 3 to 4, 14 to 21, and 49 to 63 after starting treatment, respectively. The primary outcome is clinical cure at the test-of-clinical-cure visit in the mITT-1 population. ^aSome participants had more than 1 exclusion.

Figure 2.. Clinical Cure Rates Among Participants With Cellulitis Treated With Cephalexin Plus Trimethoprim-Sulfamethoxazole or Cephalexin Plus Placebo in the Modified Intention-to-Treat, Per-Protocol, and FDA Guidance Early End-Point Populations

See Table 1 for a description of the per-protocol, modified intention-to-treat (mITT-1 and mITT-2), and US Food and Drug Administration (FDA) guidance early end-point (response rate reported) populations and outcome definitions. Dashed lines indicate the 10% predetermined threshold of clinically significant difference.