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Piperacillin-Tazobactam Alternatives: General Recommendations
Piperacillin-Tazobactam Alternatives: General Recommendations
Piperacillin-tazobactam (P/T) is one of the most common antibiotics used at Nebraska Medicine. It has a
broad spectrum covering Streptococci, penicillin-sensitive Enterococci and Staphylococci, enteric gram
negative rods, Pseudomonas species, and anaerobic bacteria. Recent data suggests its use, particularly
in combination with vancomycin significantly increases the risk of acute kidney injury (AKI) even in
patients at low risk for AKI. Rates of AKI approach 30% with combination use compared to 10% with
vancomycin alone. While P/T is a highly effective antibiotic with many advantages, the consequences of
AKI are substantial - resulting in significant patient harm and prolonged length of stay. With that in
mind, we have produced the following guidance regarding use of combinations of vancomycin and P/T.
Links to our clinical guidelines are included.
General Recommendations:
Vancomcyin is overused and should only be used when a significant risk for MRSA infection
exists. Examples of appropriate use would include: Hospital or Ventilator-associated Pneumonia
(HAP/VAP), Severe purulent skin and soft tissue or bone and joint infection, Sepsis presumed
due to central venous catheter infection, and nosocomial sepsis of unknown etiology.
P/T is overused. While it may be appropriate for nosocomial infections, most community-onset
infections do not require coverage for Pseudomonas
o The most common indications for P/T use at NM include: pneumonia, intra-abdominal
infection, presumed sepsis, skin and soft tissue and bone and joint infections, and UTI
o P/T use in SSTI and bone and joint infections and many cases of UTI is inappropriate
Just because a patient has “sepsis” doesn’t mean they need vancomycin and P/T
o Utilize institutional guidelines to assist with appropriate therapy choices based on the
most likely organisms at each source
Community-onset pneumonia:
o P/T is not appropriate for CAP
o Vancomycin should only be considered in severe CAP after influenza
o https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/cap-
guideance-2015-revision.pdf
Healthcare-associated/Nosocomial pneumonia:
o Consider substituting cefepime for P/T
o https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/hcap-
hap-vap-guidance-2015-revision.pdf
2. Gomes DM, Smotherman C, Birch A, et al. Comparison of acute kidney injury during treatment
with vancomycin in combination with piperacillin-tazobactam or cefepime. Pharmacotherapy
2014; 34:662–9.
3. Navalkele B, Pogue JM, Karino S, Nishan B, Salim M, Solanki S, et al. Risk of Acute Kidney Injury
in Patients on Concomitant Vancomycin and Piperacillin-Tazobactam Compared to Those on
Vancomycin and Cefepime. Clinical Infectious Diseases. 2017; 64:116-23
4. Hammond DA, Smith MN, Painter JT, Meena NK, Lusardi K. Comparative incidence of acute
kidney injury in critically ill patients receiving vancomycin with concomitant piperacillin-
tazobactam or cefepime: a retrospective cohort study. Pharmacotherapy 2016; 36:463–71.