Is it better to add Tazocin (piperacillin/tazobactam) + Vancomycin to Levofloxacin in a patient with Community-Acquired Pneumonia (CAP) who is not improving?

From the Guidelines

For a patient with community-acquired pneumonia (CAP) not responding to levofloxacin, switching to piperacillin-tazobactam (Tazocin) plus vancomycin is a reasonable approach, as recommended by the 2019 American Thoracic Society and Infectious Diseases Society of America guidelines 1. This combination provides broader coverage against resistant organisms that might be causing treatment failure. Piperacillin-tazobactam, typically dosed at 4.5g IV every 6-8 hours, covers many gram-negative and anaerobic bacteria, while vancomycin (15 mg/kg every 12 hours, with adjustments based on levels) addresses MRSA and other resistant gram-positive organisms, as outlined in the 2016 ATS/IDSA HAP/VAP guidelines referenced in 1.

Key considerations when switching antibiotics include:

• Obtaining cultures (blood, sputum) to identify the pathogen and its sensitivities, allowing for potential de-escalation of therapy 1
• Evaluating for complications like empyema or lung abscess with imaging
• Monitoring renal function due to potential nephrotoxicity from vancomycin The treatment duration should typically be 7-14 days, depending on clinical response and the pathogen identified. This approach is supported by the most recent guidelines, which emphasize the importance of covering resistant pathogens, such as Pseudomonas aeruginosa, MRSA, or beta-lactamase-producing organisms, in patients not responding to initial therapy 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment of Community-Acquired Pneumonia (CAP)

• The patient is currently being treated with levofloxacin for CAP but is not improving.
• According to 2, for patients with severe community-acquired pneumonia or who are admitted to the intensive care unit, treatment with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone is recommended.
• Additionally, 2 suggests that those with risk factors for Pseudomonas should be treated with a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem, doripenem, or cefepime), plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin).
• Those with risk factors for methicillin-resistant Staphylococcus aureus should be given vancomycin or linezolid, as stated in 2.

Use of Tazocin + Vancomycin

• Tazocin (piperacillin/tazobactam) is a beta-lactam antibiotic that can be used in combination with vancomycin for the treatment of CAP, especially in patients with risk factors for Pseudomonas or methicillin-resistant Staphylococcus aureus.
• According to 3, hospitalized patients without risk factors for resistant bacteria can be treated with β-lactam/macrolide combination therapy, such as ceftriaxone combined with azithromycin, for a minimum of 3 days.
• However, for patients with risk factors for resistant bacteria, a more broad-spectrum antibiotic regimen such as tazocin + vancomycin may be necessary, as suggested in 2.

Levofloxacin Treatment

• Levofloxacin is a fluoroquinolone that has a broad spectrum of activity against several causative bacterial pathogens of CAP, as stated in 4 and 5.
• The efficacy and tolerability of levofloxacin 500 mg once daily for 10 days in patients with CAP are well established, according to 4.
• However, if the patient is not improving on levofloxacin, it may be necessary to consider alternative treatment options, such as tazocin + vancomycin, especially if there are risk factors for resistant bacteria.