Piperacillin Vancomycin

The patient was admitted to the hospital with a presumptive diagnosis of health care-associated pneumonia (based on the recent hospitalization). He received intravenous hydration with normal saline, 5 L oxygen via face mask, an insulin infusion to control his glucose, and empirical antimicrobial therapy with piperacillin-tazobactam 2.25 g intravenously every 6 hours and vancomycin 1 g intravenously every 24 hours. All other medications are continued with the exception of the diabetes medications. 

Insufficiency SO years) peripheral neuropathy Enterobacteriaceae, P. aeruginosa, Enterococcus spp., anaerobes Vancomycin PLUS (1) piperacillin/tazobactam (2) imipenem/cilastatin or meropenem (3) cefepime or ceftazidime and clindamycin or metronidazole (4) ciprofloxacin or levofloxacin and clindamycin or metronidazole... 

Treatment for septic patients with hospital-acquired, ventilator-acquired, and health care-associated pneumonia is dependent on risk factors for multi-drug resistant (MDR) organisms (Fig. 79-2). Recommended treatment for patients with no MDR risk factors are third-generation cephalosporins, fluoroquinolones, ampicillin-sulbactam, or ertapenem (see Table 79-3).35 Recommended treatment for patients with MDR risk factors are P-lactam/p-lactamase inhibitors (piperacillin-tazobactam), antipseudomonal cephalosporin, or carbapenem, plus an aminoglycoside, plus vancomycin or linezolid (see Table 79-3).35 If an aminoglycoside is undesirable, a antipseudomonal fluoroquinolone may be utilized with a P-lactam/p-lactamase inhibitor. 

A 43-year-old male in the surgical ICU after exploratory laparotomy following a motor vehicle accident develops fever that is unresponsive to broad-spectrum antibacterial therapy (piperacillin-tazobactam 3.75 g every 6 hours, gentamicin 120 mg every 8 hours, and vancomycin 1 g every 12 hours). The patient has a central venous catheter and a Foley catheter. Blood cultures are negative at the time, but the patient has yeast growing in the sputum and urine. Laboratory studies reveal a white blood cell count of 11,300 cells/mm3 (11.3 x 109/L). 

Unknown Piperacillin or ceftazidime/cefepime or imipenenYmeropenem + gentamicin vancomycin... 

Septicemia 6 Any Vancomycin + cephalosporin (third-generation) or piperacillin/tazobactam or imipenem or meropenem ... 

Septicemia Any Vancomycin + aminoglycos generation) or piperacillin + ide + cephalosporin (third-tazobactam... 

Reports of drug-induced thrombocytopenia have been systematically reviewed (1). Among the 98 different drugs described in 561 articles the following antibiotics were found with level I (definite) evidence co-trimoxa-zole, rifampicin, vancomycin, sulfisoxazole, cefalothin, piperacillin, methicillin, novobiocin. Drugs with level II (probable) evidence were oxytetracycline and ampicillin. 

In a randomized, prospective, cost-effectiveness study both teicoplanin and vancomycin were assessed as second-line therapy in 66 neutropenic patients after the failure of empirical treatment with a combination of piperacillin -I- tazobactam and amikacin (10). The primary success of second-line therapy was equivalent, and the direct total costs were similar. Acquisition costs per dose were in favor of vancomycin, but costs derived from administering vancomycin and serum concentration monitoring led to similar costs for both regimens. With the exception of the red man syndrome, which occurred in 10% of vancomycin-treated patients but none of the tei-coplanin-treated patients, toxicity (renal, liver, and ear toxicity, diarrhea, phlebitis) was also similar. 

Kureishi A, Jewesson PJ, Rubinger M, Cole CD, Reece DE, Phillips GL, Smith JA, Chow AW. Double-blind comparison of teicoplanin versus vancomycin in febrile neutropenic patients receiving concomitant tobramycin and piperacillin effect on cyclosporin A-associated nephrotoxicity. Antimicrob Agents Chemother 1991 35(ll) 2246-52. 

Results from animal studies indicate that while furosemide enhanced cephaloridine nephrotoxicity no increased renal toxicity was observed by combining of piperacillin with furosemide [142]. Latamoxef and flo-moxef may decrease nephrotoxicity of vancomycin by inhibiting its uptake into the kidney [146,147]. The results of a retrospective study including renal transplant patients indicate that aztreonam can be safely administered with cyclosporine [148]. Combination therapy with ampicillin/aztreonam in neonates showed a lower renal toxicity than in the group with concurrent administration of oxacillin/ amikacin [149]. 

Sulfonamides Choramphenicol Rifampin Ethionamide Metronidazole Therapeutic Levels Penicillin G Carbenicillin Nafcillin Piperacillin Cefotaxime Ceftriaxone Imipenem Meropenem Vancomycin Vidarabine Flucytosine Pyrimethamine Acyclovir Linezolid Colistin... 

Skin/soft tissue Catheter-related Unknown Nafcillin or cefazolin Ceftriaxone -I-/- vancomycin Vancomycin Piperacillin or ceftazidime-cefipime 1 or meropenem -l-gentamicin -P/— vancomycin... 

At least four different types of empirical parenteral antibiotic regimens are in use (1) monotherapy with an antipseudomonal cephalosporin (cefepime or ceftazidime) or antipseudomonal car-bapenem (imipenem-cilastatin or meropenem), (2) combination therapy with an aminoglycoside plus an antipseudomonal penicillin (piperacillin-tazobactam or ticarciUin-clavulate), an antipseudomonal cephalosporin, or an antipseudomonal carbapenem, (3) vancomycin plus an antipseudomonal cephalosporin or antipseudomonal carbapenem, with or without an aminoglycoside, and (4) a fluoroquinolone (ciprofloxacin or levofloxacin) in combination with an... 

Noninterfering acetaminophen, amoxicillin, ampicillin, aspirin, aztreonam, caffeine, ce-famandole, cefotiam, cefsulodin, ceftazidime, ceftriaxone, cefuroxime, cephaloridine, ce-phalothin, chlorpheniramine, gentamicin, moxolactam, nafcillin, piperacillin, pseudoe-phedrine, theophylline, ticarcillin, vancomycin... 

Noninterfering amikacin, apalcillin, carbenicillin, cefoperazone, clindamycin, eiythromy-cin, gentamicin, penicillin, piperacillin, ticarcillin, tobramycin, vancomycin... 

A randomised, crossover study in 9 healthy subjects found that infusions of vancomycin 500 mg and piperacillin 3 g with tazobactam 375 mg had little or no effect on the pharmacokinetics of any of the antibacterials, except that the piperacillin AUC was slightly raised, by about 7%. It was concluded that no dosage adjustments are needed if these drugs are given together. ... 

Neuromuscular fuuction Neuralgic amyotrophy with bilateral shoulder pain and stiffness developed in a 22-year-old man with cystic fibrosis taking vancomycin, tobramycin, and piperacillin/tazobactam the symptoms persisted for 2 months and recurred when the same antibiotics were given 8 months later [90 ]. 

In an elderly woman, who had already had a maculopapular rash after intravenous vancomycin in combination with piperacillin/tazobactam and metronidazole, a pruritic rash developed after exposure to oral vancomycin for C. difficile infection [97 ]. 

An anaphylactic reaction was reported following 500 mg of oral vancomycin to treat severe Clostridium difficile infection. The patient was a 35-year-old posttransplant cystic fibrosis man who had several documented IgE reactions to antibiotics including cefepime, piperacillin as well as latex [81 ]. Five patients over a period of 4years at the Massachusetts General Hospital were reported to have developed DRESS syndrome in association with vancomycin use. Onset of symptoms varied from 12 days to 4 weeks after starting treatment and should be considered in subjects presenting late with typical findings [82 ]. 

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