One-dose vancomycin for SSTIs: Just don’t do it

You are managing an otherwise healthy patient with cellulitis but no abscess to poke. You decide this patient needs antibiotics but is stable enough to go home.

“Give em’ a dose of vanc before they go,” right?

Here is why giving one-dose vancomycin for SSTIs in stable patients is a bad idea:

NO evidence that this shows any benefit.
Not recommended by the Infectious Diseases Society of America (IDSA)¹
Extends the patient’s ED stay by at least an hour for the IV infusion
Increases the cost of the ED visit (IV line, medication, RN time)
Pharmacokinetically 1 dose of vancomycin makes no sense for SSTIs
- – 1 gm IV x 1 is sub-therapeutic for decent adult kidneys
- – Effective bug-killing is based on drug levels achieved with repeated dosing over several days
Subtherapeutic vancomycin concern in the age of multi-drug resistant (MDR) organisms
- Check out this 2009 editorial in the New England Journal of Medicine on antibiotic-resistant bugs in the 21st century.

Here is how I approach consults for uncomplicated SSTI antibiotics:

Some will argue that we should still give SSTI patients one dose of IV antibiotics and send them out on the same PO antibiotics – i.e. clindamycin. Remember that infusion time for IV antibiotics is usually 30-60 minutes, the same time it takes for the antibiotics to be absorbed from the GI tract, so giving 1 dose of IV antibiotics as a “load” before discharge is not necessary.

Oral antibiotics commonly used for SSTIs and their bioavailability (source – package inserts):

Clindamycin ~90%
Sulfamethoxazole/Trimethoprim ~100%
Doxycycline ~100%
Linezolid ~100%

Would love your feedback!

Reference

1.
Liu C, Bayer A, Cosgrove S, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52(3):285-292. https://www.ncbi.nlm.nih.gov/pubmed/21217178.