Vancomycin and Piperacillin-tazobactam (Zosyn) are two widely used broad spectrum antibiotics most ED providers use severe infections and especially undifferentiated sepsis. These antibiotics together synergistically fight off  MRSA, Pseudomonas, and other dangerous gram negative and gram positive infections for our sick patients.  Often times we use Vanc and Zosyn without considering other antibiotic therapy options because maybe we are familiar with it and we know it works. We don’t always consider the side effects that could be associated with using these antibiotics so frequently. Could we be putting our patients’ kidneys in harms way? Possibly….

It’s actually been well studied that the combination of Vancomycin plus Zosyn (VPT) is associated with increased risk of acute kidney injury compared to either drug as monotherapy or other vancomycin/β-lactam combos. In a recent prospective, multicenter observational study in 2018 the incidence of nephrotoxicity in patients receiving IV vancomycin in combination with cefepime, meropenem, or piperacillin/tazobactam was compared. The study involved 242 patients. It was concluded that the combination of Vanc and Zosyn together increased the incidence of AKI in patients significantly more than those treated with Vanc, Meropenem, and Cefepime.

  • Incidence of AKI with Vanc +Zosyn: 29.8%
  • Incidence of AKI with Vanc, Meropenem, or Cefepime monotherapy: 8.8%

Bottom Line:  Patients receiving vancomycin and zosyn were 6.7 times more likely to develop acute kidney injury compared with other broad spectrum antibiotic combinations. We should consider other antibiotic alternatives if possible instead of always grabbing the Vanc/Zosyn duo.

Shout out to the deeply missed Jeff Nusbaum in Pittsburgh for the Pearl inspiration =)


1.) 2010Vancomycin-associated nephrotoxicity: grave concern or death by character assassination? Am J Med 123:182.e1–182.e7.doi:10.1016/j.amjmed.2009.05.031

2.) Are Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at Higher Risk for Acute Renal Injury?  Ann Emerg Med. 2018 Oct;72(4):467-469. doi: 10.1016/j.annemergmed.2018.06.004. Epub 2018 Jul 27

July 2024