Piperacillin–Tazobactam Plus Vancomycin-Associated Acute Kidney Injury in Adults: Can Teicoplanin or Other Antipseudomonal Beta-Lactams Be Remedies?

Numerous observational studies and meta-analyses have suggested that combination therapy consisting of piperacillin–tazobactam (TZP) and vancomycin (VAN) augments acute kidney injury (AKI) risk when compared to viable alternatives, such as cefepime–vancomycin (FEP–VAN) and meropenem–VAN. However, the exact pathophysiological mechanisms of this phenomenon are still unclear. One major limitation of the existing studies is the utilization of serum creatinine to quantify AKI since serum creatinine is not a sufficiently sensitive and specific biomarker to truly define the causal relationship between TZP–VAN exposure and nephrotoxicity. Even so, some preventive measures can be taken to reduce the risk of AKI when TZP–VAN is preferred. These measures include limiting the administration of TZP–VAN to 72 h, choosing FEP–VAN in place of TZP–VAN in appropriate cases, monitoring the VAN area under the curve level rather than the VAN trough level, avoiding exposure to other nephrotoxic agents, and minimizing the prescription of TZP–VAN for patients with a high risk of AKI. More data are needed to comment on the beneficial impact of the extended-infusion regimen of TZP on nephrotoxicity. Additionally, TZP and teicoplanin can be reasonable alternatives to TZP–VAN for the purpose of lowering AKI risk. However, the data are scarce to advocate this practice convincingly.