Is vancomycin (Vanco) IV okay for treating a chest wall abscess after incision and drainage (I&D)?

Management of Chest Wall Abscess After Incision and Drainage

Intravenous vancomycin is an appropriate treatment for chest wall abscess after incision and drainage, especially when MRSA is suspected or confirmed. 1

Antibiotic Selection Rationale

Vancomycin IV is indicated for the treatment of abscesses, particularly when:

• MRSA is suspected or confirmed
• The infection is complicated or extensive
• The patient has systemic symptoms
• The patient is immunocompromised

Dosing Recommendations

• Standard dosing: 15-20 mg/kg/dose (actual body weight) every 8-12 hours, not to exceed 2 g per dose 1, 2
• For seriously ill patients: Consider a loading dose of 25-30 mg/kg 1
• Monitor trough concentrations at steady state (before 4th or 5th dose) 1
• Adjust dosing based on renal function 2

Treatment Algorithm

1. Surgical Management:

   • Ensure adequate incision and drainage has been performed 1
   • Break up loculations if present
   • Consider obtaining cultures during the procedure

2. Antibiotic Therapy:

   • Begin IV vancomycin immediately after cultures are obtained
   • Duration typically 1-2 weeks, depending on clinical response
   • Consider transition to oral therapy when clinically improving 3

3. Monitoring:

   • Assess clinical response within 48-72 hours
   • Monitor vancomycin trough levels
   • Follow inflammatory markers (ESR, CRP) to track response 1

Alternative Antibiotic Options

If vancomycin is not appropriate or the patient fails to respond:

• Linezolid 600 mg PO/IV twice daily 1
• Daptomycin 6 mg/kg/dose IV once daily 1
• TMP-SMX 4 mg/kg/dose (TMP component) twice daily 1
• Clindamycin 600 mg every 8 hours (if susceptible) 1

Important Considerations

• Vancomycin penetrates well into soft tissue infections but may have inadequate concentrations in large abscesses 4
• The combination of surgical drainage plus appropriate antibiotics is essential for optimal outcomes 4
• For large or complex abscesses, some experts recommend adding rifampin 600 mg daily or 300-450 mg twice daily after clearance of any bacteremia 1

Potential Pitfalls

• Inadequate drainage is associated with high recurrence rates
• Vancomycin alone may be insufficient for polymicrobial infections
• Vancomycin requires therapeutic drug monitoring to ensure adequate dosing
• Early transition to oral therapy should be considered when clinically appropriate to reduce hospital length of stay 3

Follow-up Recommendations

• Re-evaluate within 48-72 hours to assess clinical response
• Consider repeat imaging if clinical improvement is not observed
• Continue antibiotics until clinical resolution of infection, typically 1-2 weeks depending on severity

Proper management with both adequate surgical drainage and appropriate antibiotic therapy is essential for successful treatment of chest wall abscesses.