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.
Reflexive vs cognitive medicine need a randomized control trial.