A 56 y/o male with poorly controlled diabetes s/p multiple toe amputations presents with several days of fever and foot pain. He is tachycardic and hypotensive and appears to have an infected foot ulcer.
Vascular surgery is paged, and agrees come to see the patient, and in the meantime tells you to start Vancomycin and Zosyn for coverage.
Should you take her suggestion?
No.
Zosyn is unnecessary overkill for most skin and soft tissue infections, including diabetic foot ulcers. Broad coverage for streptococci, MRSA, aerobic gram-negative bacilli AND anaerobes can be accomplished through either:
Trimethoprim-sulfamethoxazole PLUS Amoxicillin-clavulanate
-OR-
Clindamycin PLUS a flouroquinolone.
Zosyn is also not the drug of choice for intra-abdominal infections at our institution due to high prevalence of ESBLs and resistant Pseudomonas.
Practically speaking, Zosyn is also not stocked in our ED (for reasons of overuse outlined above). Sepsis goals are now being very closely tracked (1. antibiotics in under an hour 2. blood cultures prior to antibiotics 3. Fluid resuscitation > 1500 ccs for all patients with a lactate of > 4 or hypotension < 90 systolic) and waiting for this medication to arrive from pharmacy will delay initial antibiotics to the patient.
Please refer to the sepsis order sets for appropriate antibiotic choices for a given infectious source. All of the medications in the sets are stocked in our ED and available to give to the patient immediately.
