For this study, I’m using a stealing a line from Amal Mattu –
“If you are thinking of giving a dose of vancomycin then discharging a patient from the ED, think again. Think about it a third time, and if you are still considering vanco, slap yourself.”
In a single center retrospective observational cohort study, consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period were evaluated. Over 18 months, 526 patients were given vanco and discharged, many with skin & soft tissue infections (70% of patients). Underdosing of vancomycin occurred in 239 (73%) patients…. and why the hell were the other 30% (or, 100 patients a year) given a single dose?!? Are they being given vanco/zosyn x 1 dose for a fever with either abdominal pain or a cough? Ugh. Terrible. I would love to think this is not the case for all institutions, but I’m sure this sort of doling out of broad spectrum antibiotics is the rule rather than the exception.
Sigh. While the underdosing does not really surprise or worry me much, this “vanco & go” dosing needs to stop.
Fortunately, I have a solution – stop ordering IV antibiotics for SSTI’s that do not meet SIRS, as they are extremely low risk for poor functional outcomes even if they bounce back. There is no reason to provide a singular IV dose and discharge unless the patient can not tolerate PO. This study – from two decades ago – showed a savings of $4 per patient when they stopped using secondary IV tubing & started with IV push antibiotics. Add in the cost a bag of normal saline being in the couple hundred dollar range, and you’re talking significant patient savings without a decline in outcomes.