For many residents, hospitalists and other physicians, vancomycin and piperacillin-tazobactam has approached reflex status.  The patient has a fever, looks sick (perhaps even septic) and has no obvious infection so we start vanc and pip/tazo.

For yours this combination bothered me, because it implied the lack of a careful thought process.  If we just write vanc and pip/tazo, then we need not think further.  If we are lucky, some culture will turn positive and we can de-escalate.  I dislike the absence of thinking.

For a few years, I thought this reflex was unique to our training program, but visiting professor status has taught me of the universal status that vanc & pip/tazo occupy.

BTW, pip/tazo has the tradename Zosyn (but I prefer to think in generic drug terms).

More recently, we have learned that this combination has a major adverse impact – increased acute kidney injury.   This article – Risk of Acute Kidney Injury in Patients on Concomitant Vancomycin and Piperacillin–Tazobactam Compared to Those on Vancomycin and Cefepime

This study shows clearly that vanc & pip/tazo have a negative synergistic impact on the kidney.  The most interesting point in the article (to me) is that vanc trough levels predict AKI in vanc/cefepime but NOT in vanc/pip-tazo.

So in 2017 I fear vanc/pip-tazo.  Patients on this combination had a length of stay averaging 2 days longer!

The housestaff with whom I work know my fear

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, and work hard to avoid the combination.  Perhaps they are actually being more thoughtful about antibiotic choices.  That would be good for our patients.