CHEST Guidelines-Does-Vancomycin-Piperacillin-Tazobactam-Cause--em-

Does-Vancomycin-Piperacillin-Tazobactam-Cause--em-

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The article explores the potential nephrotoxic effects of combining vancomycin with piperacillin-tazobactam (VPT) in critically ill patients, primarily focusing on whether VPT causes pseudo-acute kidney injury (pseudo-AKI) or true nephrotoxicity. The use of VPT has raised concerns due to reports of increased acute kidney injury (AKI) rates in both small and large cohort studies, although no definitive prospective clinical trials have been conducted.<br /><br />Vancomycin is known for its nephrotoxic potential, while piperacillin-tazobactam traditionally isn't, except for its potential to cause allergic interstitial nephritis. Many studies that show increased AKI risks with VPT have been retrospective, primarily reporting stage 1 AKI without showing significant increase in severe stages requiring renal replacement therapy (RRT) or resulting in mortality. This has led to hypotheses about pseudo-nephrotoxicity, where increased serum creatinine in VPT patients might be due to impaired creatinine secretion rather than actual kidney damage.<br /><br />However, some evidence suggests true nephrotoxicity with VPT, such as higher urinary kidney stress biomarkers indicating renal tubular toxicity. The study by Chen et al. supports this, revealing increased risks of both stage 2 and 3 AKI and higher incidences of RRT initiation with VPT compared to other combinations like vancomycin plus cefepime (VC) and vancomycin plus meropenem (VM).<br /><br />Authors emphasize that current retrospective evidence suggests a real risk of nephrotoxicity with VPT, and decisions regarding antibiotic therapy in ICUs should take this potential into account, although choices should also consider specific infection sources, expected pathogens, and local resistance profiles. The authors call for more definitive randomized trials to clearly delineate the nephrotoxicity risk associated with VPT.<br /><br />Overall, the article highlights the complex nature of determining drug-induced nephrotoxicity and the need for more detailed research to guide safer clinical decision-making.

Keywords

nephrotoxicity

vancomycin

piperacillin-tazobactam

acute kidney injury

pseudo-AKI

renal replacement therapy

critically ill patients

retrospective studies

urinary kidney biomarkers

randomized trials