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Concomitant vancomycin, piperacillin/tazobactam associated with increased risk for AKI
Patients receiving concomitant vancomycin and piperacillin or tazobactam faced a greater risk for acute kidney injury than those who received a combination of vancomycin and cefepime, according to data from a retrospective matched cohort study.
“A hospital’s selection of piperacillin/tazobactam vs. cefepime as the ‘workhouse’ anti-pseudomonal antibiotic has traditionally been based on institutional susceptibility trends, acquisition costs and other formulary considerations,” Infectious Disease News Editorial Board member Keith S. Kaye, MD, MPH, of the department of medicine at Detroit Medical Center and Wayne State University School of Medicine, and colleagues wrote. “Concerns regarding nephrotoxicity have become increasingly prominent. While vancomycin has long been associated with acute kidney injury, recent evidence suggests that patients receiving combination therapy with piperacillin/tazobactam have a higher incidence of acute kidney injury compared to patients receiving vancomycin monotherapy or those receiving combination therapy with vancomycin and cefepime. However, the finding of increased toxicity in patients receiving vancomycin and piperacillin/tazobactam combination therapy compared to vancomycin and cefepime has not been universal.”
The researchers studied 558 patients admitted to the Detroit Medical Center between Dec. 1, 2011 and Dec. 31, 2013. Patients were given a combination of vancomycin and cefepime or vancomycin and piperacillin/tazobactam for 48 hours or more. Patients in each group were matched based on illness severity, duration of therapy, vancomycin dose, ICU status and concomitant nephrotoxins. The primary endpoint was the incidence of acute kidney injury.
Mean age was 55.9 years. Patients in the vancomycin and piperacillin/tazobactam group had a significantly higher rate of acute kidney injury than those in the vancomycin and cefepime group (29% vs. 11%), the researchers reported. A multivariate analysis showed that vancomycin and piperacillin/tazobactam was an independent predictor of acute kidney injury (HR = 4.27; 95% CI, 2.73-6.68). Additionally, median onset of acute kidney injury was more rapid in the vancomycin and piperacillin/tazobactam group than in the vancomycin and cefepime group (3 days vs. 5 days; P ≤ .0001).
“In conclusion, therapy with vancomycin and piperacillin/tazobactam was independently associated with a four-fold increased risk of acute kidney injury compared to combination therapy with vancomycin and cefepime. Additionally, acute kidney injury with vancomycin and piperacillin/tazobactam occurred in a more rapid fashion,” Kaye and colleagues wrote. “Despite this rapid onset of acute kidney injury, there are opportunities for providers to limit the incidence of this adverse event … timely de-escalation or discontinuation of one or both of the combination agents would likely mitigate acute kidney injury risk.” – by Andy Polhamus
Disclosure: The researchers report no relevant financial disclosures.