Vanco with Cephalosporin

[Pharmacy Kid]

What's the purpose of putting a patient on both IV vanco and IV cephalosporin for cellulitis? The only thing I can think of is if a doc is waiting for a culture and then will deescalate to one or the either. However, doesn't vanco cover both strep, mssa and mrsa?

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[zelman]

What's the purpose of putting a patient on both IV vanco and IV cephalosporin for cellulitis? The only thing I can think of is if a doc is waiting for a culture and then will deescalate to one or the either. However, doesn't vanco cover both strep, mssa and mrsa?

I’m bad at ID, but is it possible they were covering for a gram negative bug for some reason? Was it an anti-pseudomonal cephalosporin?

 

[bacillus1]

As said above, there might be need for Pseudomonal coverage with anti-Pseudomonal cephalosporin if a diabetic foot ulcer (e.g. if patient soaks feet in water). There are other specific scenarios as well, such as gram negative bug on culture, or neutropenic fever.

 

[Pharmacy Kid]

The cephalosporin was cefazolin so it doesn't look like pseudomonal coverage. Possibly added for some gram - coverage. Pt has uncontrolled T2DM, venous insufficiency, CKD, and morbid obesity.

 

[TimeZero]

Cefazolin is now the DOC for MSSA, even when vanco is on board. Go check out figure 1 in the IDSA SSTI guidelines, it's pretty sweet. As for needing both agents, was the patient septic? How bad was the cellulitis? I'm guessing it was hard to tell exactly what was going on given the patient's comorbidities.

 

[El Trombopag]

What's the purpose of putting a patient on both IV vanco and IV cephalosporin for cellulitis? The only thing I can think of is if a doc is waiting for a culture and then will deescalate to one or the either. However, doesn't vanco cover both strep, mssa and mrsa?

I see things like this often, and my thought is that sstis are the most mistreated infections out there. Huge prescriber variability, training, experience. The only ‘double coverage’ empiric combo I don’t throw too much of a fit over is PO Bactrim plus QID cephalexin. Because at least getting to PO is a win. Gram negatives really don’t need to be empirically covered except for diabetic feet, osteo, maybe nec fasc, patients with signs of sepsis due to the ssti.
One thing to watch for with ssti diagnoses is making sure there’s not something else on the differential—like ruling out endocarditis or something while the active problem still looks like cellulitis

 

[SpartanDOnoharm]

I see things like this often, and my thought is that sstis are the most mistreated infections out there. Huge prescriber variability, training, experience. The only ‘double coverage’ empiric combo I don’t throw too much of a fit over is PO Bactrim plus QID cephalexin. Because at least getting to PO is a win. Gram negatives really don’t need to be empirically covered except for diabetic feet, osteo, maybe nec fasc, patients with signs of sepsis due to the ssti.
One thing to watch for with ssti diagnoses is making sure there’s not something else on the differential—like ruling out endocarditis or something while the active problem still looks like cellulitis

Bactrim and cephalexin makes sense because Bactrim isn't great at covering strep.

Vanco and cefazolin can be a possible combo for a few different diagnosis, particularly endocarditis, waiting empiric therapy, or in a patient where you want more bactericidal activity than the vanco can offer.

 

[PolarPop]

The thought behind this combination is that if vancomycin is given alone and the cellulitis is caused by MSSA/Strep, then they are giving an inferior drug. There’s not much to support it though outside of bacteremia/endocarditis. Most combination studies for cellulitis (including bactrim/keflex) ended up being of no benefit although there may be one or two out there i’m not thinking of.

A good doc can look at a cellulitis and tell whether it is from Strep or Staph. If it’s due to Strep, cefazolin alone is fine. If it’s Staph then vancomycin alone is fine until susceptibilities are back.

 

[VA Hopeful Dr]

A good doc can look at a cellulitis and tell whether it is from Strep or Staph. If it’s due to Strep, cefazolin alone is fine. If it’s Staph then vancomycin alone is fine until susceptibilities are back.

Not 100%. And that's the standard we're held to.

 

[AlPacino]

What's the purpose of putting a patient on both IV vanco and IV cephalosporin for cellulitis? The only thing I can think of is if a doc is waiting for a culture and then will deescalate to one or the either. However, doesn't vanco cover both strep, mssa and mrsa?

Empiric coverage until they have a better idea of what the cause is. That are most ED docs are always rushing so they throw the entire kitchen sink to anyone presenting with some redness. Also depends on the nature of the cellulitis. For a nonpurulent, closed, absence of SIRS symptoms, Erysipelas cellulitis, I don't think its necessary to cover for MRSA unless pt has a history of MRSA cellulitis. A third-generation cephalosporin like Ceftriaxone or Cefepime(for pseudomonal coverage) should suffice. Sometimes doc want to add anerobic coverage(not offered by vanco) and a 2nd gen Cephalosporin like Cefoxitin is used or they just add Metronidazole to Ceftriaxone. Also wound cultures are not that reliable and often manifest as polymicrobial due to contamination. My hospital recently started authorizing a pharmacist to order MRSA wound PCR so at least help de-escalate coverage and d/c vanco. I think Vanco is unnecessary in like 70-80% of Cellulitis infections I deal with.

Yes, Vanco does cover MSSA, Strep, but generally reserved for MRSA. There are other antimicrobials with superior coverage to MSSA and group A strep that are cheaper and not as invasive as IV Vanco.

 

[Carboxide]

I see things like this often, and my thought is that sstis are the most mistreated infections out there. Huge prescriber variability, training, experience. The only ‘double coverage’ empiric combo I don’t throw too much of a fit over is PO Bactrim plus QID cephalexin. Because at least getting to PO is a win. Gram negatives really don’t need to be empirically covered except for diabetic feet, osteo, maybe nec fasc, patients with signs of sepsis due to the ssti.
One thing to watch for with ssti diagnoses is making sure there’s not something else on the differential—like ruling out endocarditis or something while the active problem still looks like cellulitis

I quasi agree. I think most of the time a general cellulitis can be dealt with using just a first gen ceph. Nec fasc should ALWAYS get full coverage - it's almost always polymicrobial, besides which it's nasty af. I also like to cover gram negs for hands and feet, and any wound that's been open and hasn't gotten treated immediately. If you have a cut on your leg and it's been festering, chances are good that something GN has gotten in there. Like most people, I prefer MRSA coverage for patients with diabetes and any hospital-associated SSTIs (surg wound, etc), as well as patients with sepsis and osteo.

Inpatient-wise, I'd like to see a lot less vanc, a MASSIVE amount less vanc/zosyn, and substantial increases in ctx or cefazolin. Outpatient wise, I think my place does ok.

 

[ldiot]

Probably the pt was septic so they wanted gram negative coverage. Cefazolin also kills MSSA better than vanco so if the pt was very sick and growing gram positive cocci they may have wanted to add cefazolin while they wait for ID/sensitivity just because it is better than vanco for a potential MSSA.

Where im at there's a lot of resistance to cefazolin, so ceftriaxone is used more

 

[Rouelle]

What's the purpose of putting a patient on both IV vanco and IV cephalosporin for cellulitis? The only thing I can think of is if a doc is waiting for a culture and then will deescalate to one or the either. However, doesn't vanco cover both strep, mssa and mrsa?

Well not to state the obvious here, but most inpatient pharmacists (at least at places I’m aware of) have access to progress notes, C&S reports, etc. Is your place the same?

 

[confettiflyer]

Inpatient-wise, I'd like to see a lot less vanc, a MASSIVE amount less vanc/zosyn, and substantial increases in ctx or cefazolin. Outpatient wise, I think my place does ok.

Oh god, the Vosyn


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