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Written by Clay Smith
Spoon Feed
The combination of vancomycin plus piperacillin-tazobactam (VPT) was associated with increased risk of acute kidney injury (AKI) compared to either drug as monotherapy or other vancomycin/β-lactam combinations, NNH = 11.
Why does this matter?
The combination of VPT is common in sepsis patients. Several papers have been published that raise concern that this combo may increase risk of AKI. This is a synthesis of some of those papers.
The sepsis combo
This was a meta-analysis of papers studying VPT and AKI and included 15 published studies, 17 abstracts, with a total of nearly 25,000 patients. They found that the VPT combo was associated with increased risk of AKI compared with vancomycin alone, piperacillin-tazobactam alone, or vancomycin combined with cefepime or a carbapenem, overall NNH = 11. Many studies defined AKI based on rise in creatinine, which may have been transient. However, the authors noted that, “even transient changes in renal function are associated with worse outcomes.” So, what are we to do? Protocols with alternative regimens to limit the frequency of VPT use is one step; cutting the duration of this therapy via deescalation is another.
Source
Are Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at Higher Risk for Acute Renal Injury? Ann Emerg Med. 2018 Oct;72(4):467-469. doi: 10.1016/j.annemergmed.2018.06.004. Epub 2018 Jul 27.
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I wanted to point out that the published articles, systematic-reviews, and meta-analysis have identified AKI with Vancomycin + Piperacillin-tazobactam with a minimum duration of at least 48 hours. This is important for the ED because we still do not know what association or effect, if any, that a single dose or short-course (e.g. < 48 hours) of combination therapy has on AKI and other relevant patient outcomes. I think this article also brings to light the dilemma of the patient who does require this combination therapy over alternative treatments and we actively need to work on strategies to limit the duration of combination therapy, especially in critically ill patients.
Thanks, Matt. Great point.