Should Zosyn (piperacillin/tazobactam) be initiated for a patient with Small Bowel Obstruction (SBO) and sepsis?

From the Guidelines

Yes, starting Zosyn (piperacillin-tazobactam) is appropriate for a patient with small bowel obstruction (SBO) and sepsis. The recommended dosing is typically 3.375g IV every 6 hours or 4.5g IV every 8 hours, with dose adjustments needed for renal impairment 1. Zosyn provides broad-spectrum coverage against gram-positive, gram-negative, and anaerobic bacteria, making it suitable for intra-abdominal infections where mixed flora are common. SBO with sepsis suggests bacterial translocation across the compromised bowel wall or potential perforation, requiring immediate antimicrobial therapy alongside other sepsis management measures including fluid resuscitation, vasopressors if needed, and source control (which may involve surgical intervention depending on the cause and severity of the obstruction) 1.

While starting Zosyn, blood cultures should be obtained before antibiotic administration if possible, and therapy should be reassessed and potentially narrowed based on culture results after 48-72 hours 1. The duration of therapy typically ranges from 5-7 days depending on clinical response, source control achievement, and resolution of sepsis markers. It is essential to follow the principles of antimicrobial stewardship, including daily assessment for de-escalation of antimicrobial therapy and consideration of local epidemiology and resistance patterns when selecting empiric therapy 1.

Some key points to consider in the management of SBO with sepsis include:

• Early initiation of broad-spectrum antimicrobial therapy, such as Zosyn, to cover likely pathogens 1
• Source control, which may involve surgical intervention, to address the underlying cause of sepsis 1
• Fluid resuscitation and vasopressor support as needed to manage sepsis-induced hypotension 1
• Monitoring for clinical response and adjustment of antimicrobial therapy based on culture results and clinical improvement 1
• Consideration of local epidemiology and resistance patterns when selecting empiric therapy 1

From the Research

Patient Management for SBO and Sepsis

• The management of a patient with Small Bowel Obstruction (SBO) and sepsis requires careful consideration of the appropriate antibiotic therapy.
• According to a study published in 2002 2, piperacillin/tazobactam is an effective antibiotic for the initial empirical treatment of intra-abdominal infections, including those caused by perforation of the large bowel or dehiscence of the anastomosis.
• However, a more recent study from 2019 3 suggests that the use of piperacillin/tazobactam may be associated with increased mortality in patients with bacteraemia due to resistant Escherichia coli or Klebsiella species.
• In the context of SBO, a study from 2019 4 recommends early empirical broad-spectrum antimicrobial therapy for patients with severe infections, including sepsis.
• Another study from 2021 5 found that the administration of antibiotics in nonoperative treatment of adhesive SBO did not reduce sepsis or mortality, but was associated with a longer hospital stay.
• A study from 2022 6 compared non-operative management (NOM) vs. surgical procedure for patients ≥ 80 years with SBO and found that NOM could yield similar results in terms of overall mortality, compared to a surgical management.

Antibiotic Therapy Considerations

• The choice of antibiotic therapy should be based on the suspected or confirmed causative pathogens and their antimicrobial susceptibility patterns.
• Piperacillin/tazobactam may be considered as an initial empirical antibiotic therapy for patients with SBO and sepsis, but its use should be guided by local antimicrobial resistance patterns and the patient's individual risk factors.
• The use of antibiotics should be carefully weighed against the potential risks of antibiotic resistance, Clostridioides difficile colitis, and other adverse effects.
• Zosyn (piperacillin/tazobactam) may be started for a patient with SBO and septic, but this decision should be made on a case-by-case basis, taking into account the patient's specific clinical circumstances and the results of microbiological cultures and susceptibility testing 2, 3, 5.