Timing of Grampositive therapy

There has been considerable debate regarding the inclusion of Gram-positive coverage (particularly vancomycin) in the initial regimen, with studies suggesting that vancomycin can be safely added later.15 However, some institutions use vancomycin because of the fulminant syndrome that can occur with viridans streptococci, including those with reduced susceptibility to penicillins, and the rise of methicillin-resistant staphylococci in patients with indwelling catheters. Vancomycin may, however, predispose to VRE infection, renal dysfunction, and rash. The Hospital Infection Control Practices Advisory Committee (HICPAC) has issued guidelines, which discourage empiric use of vancomycin except in situations where the risk of omitting it is high.16 However, the benefits may still outweigh the risks at some centers with a high rate of methicillin resistance.

Some centers choose to add vancomycin secondarily if there is no response to the initial regimen. Another strategy is to include vancomycin initially, then omit it after 48 h if cultures are negative and the catheter site shows no sign of infection. Serum trough levels of vancomycin should be monitored, and adjustments made for changing renal function. Many centers include vancomycin in the initial regimen of a critically ill patient, or when there is an evidence of catheter-related infection.

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