472. Rethinking the Role of Clindamycin for Toxin-Mediated Illnesses

BACKGROUND: Treatment of toxin-mediated diseases such as toxic shock syndrome (TSS) and Staphylococcus scalded skin syndrome (SSSS) typically includes adjunctive clindamycin to halt bacterial exotoxin production. However, there is emerging clindamycin resistance in Staphylococcus aureus and Streptococcus pyogenes. We compared pathogen susceptibilities, clinical features, and outcomes of patients with toxin-mediated diseases to evaluate the role of adjunctive clindamycin in a contemporary setting. METHODS: Epic was queried for patients < 18 years of age admitted to Inova Fairfax Hospital from January 1, 2009 to December 31, 2018. Patients were identified by ICD-9 and ICD-10 codes for TSS and SSSS and validated by manual chart review. TSS cases were classified as possible, probable, or confirmed, and SSSS cases were classified as probable or confirmed. Early antimicrobial use was defined as administration within the first 3 days of admission. Clindamycin, aminoglycosides, tetracyclines, and linezolid were considered antimicrobial agents with anti-toxin effect. RESULTS: There were 32 cases of TSS, 38 cases of SSSS, and 1 case of bullous impetigo. S.aureus (30) and S.pyogenes (8) were the most common pathogens recovered with 1 case of MRSA. Vancomycin was given to 40 patients. 45% of S.aureus isolates were clindamycin resistant; no S.pyogenes isolates were clindamycin resistant. Fifty-eight patients received early anti-toxin agents: 51 received clindamycin, 4 received clindamycin and doxycycline, 1 received clindamycin and gentamicin, 1 received doxycycline, and 1 received gentamicin. 13 did not receive any early anti-toxin agent. 42% of patients who received early clindamycin had a clindamycin-resistant S. aureus. The presenting features, number of TSS and SSSS cases, need for intensive care, median length of stay, and 30-day readmissions did not significantly differ based on early anti-toxin agent use or based on clindamycin susceptibility. There were no deaths. CONCLUSION: Withholding anti-toxin agents early in the course of illness or giving clindamycin to a resistant organism in toxin-mediated diseases did not adversely affect patient outcomes or mortality. Opportunities remain to decrease the use of empiric vancomycin and re-evaluate the role of clindamycin for toxin-mediated diseases. DISCLOSURES: All authors: No reported disclosures.