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%
- 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.