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Comment & Response
August 2018

Acute Kidney Injury Due to Concomitant Vancomycin and Piperacillin-Tazobactam

Author Affiliations
  • 1Toronto General Hospital, Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2Division of Clinical Pharmacy, University Health Network, Toronto, Ontario, Canada
JAMA Intern Med. 2018;178(8):1137. doi:10.1001/jamainternmed.2018.2930

To the Editor Bergstrom and colleagues present a very important case that highlights the dangers of medical overuse and specifically brings to light an increasingly recognized adverse event of acute kidney injury due to concomitant vancomycin and piperacillin-tazobactam.1 The Infectious Diseases Society of America guidelines do not routinely recommend empirical vancomycin use, and, as the authors highlight, this patient was low risk and did not have an indication for additional gram-positive coverage with intravenous vancomycin.2 This is especially important given the emerging data that concomitant use of vancomycin with piperacillin-tazobactam independently puts patients at risk of acute kidney injury. A 2017 systematic review and meta-analysis of 14 observational studies involving 3549 patients found a more than 3-fold increased risk of acute kidney injury with vancomycin and piperacillin-tazobactam when compared with vancomycin alone or in combination with another β-lactam (including cefipime or carbapenem).3 Following this, a more recent systematic review and meta-analysis in 2018 involving more than 24 000 patients found that the rate of acute kidney injury was 22.2% for vancomycin and piperacillin-tazobactam vs 12.9% for comparators (eg, vancomycin plus cefipime, vancomycin plus carbapenem, monotherapy with vancomycin or piperacillin-tazobactam), yielding a number needed to harm of 11.4

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