Pharmacists' perceptions and practice changes resulting from emergence of the vancomycin‐piperacillin/tazobactam nephrotoxicity phenomenon

Abstract

Purpose To elucidate the considerations pharmacists have when using concomitant vancomycin and piperacillin/tazobactam (VPT) and strategies implemented across hospitals in response to published data on this phenomenon. Methods A survey of pharmacist members of the infectious diseases and critical care (CC) practice and research networks of the American College of Clinical Pharmacy was conducted. Participants were grouped based on their belief (yes or no) in the association between VPT and acute kidney injury (AKI) and queried regarding AKI with VPT, antimicrobial stewardship practices, and demographics. Descriptive statistics were performed. Between‐group responses were compared using χ2 or Fisher's exact tests. Results There were 238 responses. Most (88.7%) respondents believed combination VPT is associated with greater expected odds of AKI development than vancomycin monotherapy or with cefepime. Nonbelievers more commonly practiced in CC or emergency medicine (P = .006) and less frequently recommended the combination in patients already experiencing AKI (64% vs 7.4%, P < .001) and in patients with chronic kidney disease class III or IV (56.9% vs 3.7%, P < .001). Opinions varied regarding risk factors for and odds of AKI development in specific scenarios. Respondents who believed combination VPT is associated with greater odds of AKI development more frequently provided formal (18% vs 0, P = .01) and informal (73% vs 33.3%, P < .001) education on potential AKI from combination VPT and discouraged empiric combination VPT in favor of other combination(s) (40.8% vs 14.8%, P = .01). Other AMS strategies were used to a similar extent regardless of belief in the association of VPT with AKI. Conclusion Most respondents, particularly those practicing in CC and emergency medicine, believe combination VPT is associated with AKI development. These beliefs have affected antimicrobial recommendations and educational efforts. The impact of these beliefs on patient outcomes and health care expenditures requires further investigation.

Progression of kidney injury with the combination of vancomycin and piperacillin-tazobactam or cefepime in sepsis-associated acute kidney injury

“…Importantly, the number of studies published on the potential nephrotoxicity of vancomycin and piperacillin-tazobactam have influenced prescribing patterns, which may have downstream implications. In a survey of infectious disease and critical care pharmacists, 89% of respondents reported a belief that the combination of vancomycin and piperacillin-tazobactam resulted in an increased probability of developing AKI compared with vancomycin alone or in combination with other beta-lactam antibiotics (5). Of those respondents, 64% reported they less frequently recommend the combination of vancomycin and piperacillin-tazobactam in a patient with existing AKI (5).…”

“…In a survey of infectious disease and critical care pharmacists, 89% of respondents reported a belief that the combination of vancomycin and piperacillin-tazobactam resulted in an increased probability of developing AKI compared with vancomycin alone or in combination with other beta-lactam antibiotics (5). Of those respondents, 64% reported they less frequently recommend the combination of vancomycin and piperacillin-tazobactam in a patient with existing AKI (5). This would appear to complicate the antibiotic selection for patients with sepsis and AKI.…”

“…These data appear to be impacting clinical practice, with a recent survey indicating a majority of clinicians are less likely to recommend combination therapy with vancomycin and piperacillin-tazobactam in a patient with preexisting AKI (5). The downstream effects of alternative combination regimens in SA-AKI include concerns with neurotoxicity (cefepime), lack of anaerobic coverage (cefepime), and antibiotic stewardship (meropenem) (6).…”

Nephrotoxic Risk Associated With Combination Therapy of Vancomycin and Piperacillin-Tazobactam in Critically Ill Patients With Chronic Kidney Disease

“…[4][5][6] These data have seemingly altered prescribing practices in critically ill patients according to a recent survey that reported almost 90% of respondents affirmed a belief that the combination of VPT increases the risk of developing an AKI. 7 However, data supporting this relationship in strictly critically ill patient populations is more nuanced. Several studies have not demonstrated increased nephrotoxicity with VPT compared with vancomycin and other β-lactam combination therapies.…”

“…4–6 These data have seemingly altered prescribing practices in critically ill patients according to a recent survey that reported almost 90% of respondents affirmed a belief that the combination of VPT increases the risk of developing an AKI. 7…”