Things that bug me 3 – vanc and pip/tazo

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Category : Medical Rants

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

Comments (1)

Reflexive vs cognitive medicine need a randomized control trial.

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