From the Guidelines
Recommendation for Additional Antibiotic Coverage
In patients clinically deteriorating on cefepime and vancomycin, adding an aminoglycoside, such as tobramycin 5-7 mg/kg IV daily, or a carbapenem, like meropenem 1g IV every 8 hours, should be considered to broaden coverage against gram-negative pathogens, including Pseudomonas aeruginosa 1.
Rationale for Choice
- Aminoglycosides offer enhanced coverage against gram-negative bacteria, including those that may be resistant to cefepime 1.
- Carbapenems, such as meropenem, provide broad-spectrum coverage, including against Pseudomonas aeruginosa and other resistant gram-negative organisms 1.
- The choice between these options should be guided by local antimicrobial resistance patterns and patient-specific factors, such as renal function and allergy history 1.
Considerations
- Local Resistance Patterns: It's crucial to consider the local epidemiology of antibiotic resistance when selecting additional antibiotic coverage 1.
- Patient Factors: Renal function, potential for nephrotoxicity with aminoglycosides, and history of allergies are important considerations in the choice of additional antibiotics 1.
- De-escalation Therapy: Once culture and sensitivity results are available, antibiotic regimens should be de-escalated to the most appropriate, narrowest-spectrum antibiotic to reduce the risk of inducing further resistance 1.
From the Research
Broadening Antibiotic Coverage
If a patient clinically deteriorates on cefepime and vancomycin, additional antibiotics may be necessary to broaden coverage. The choice of additional antibiotic(s) depends on various factors, including the suspected or confirmed pathogen, local resistance patterns, and the patient's clinical condition.
Considerations for Additional Antibiotics
- Piperacillin-tazobactam may not be the best choice due to the increased risk of acute kidney injury (AKI) when combined with vancomycin, as shown in studies 2, 3, 4.
- Cefepime/taniborbactam may be a potential option, given its broad-spectrum activity against Gram-negative bacterial pathogens, including those producing extended-spectrum beta-lactamases (ESBLs) and carbapenem-resistant Enterobacterales 5.
- Other antibiotics, such as meropenem or ceftazidime/avibactam, may also be considered, depending on the specific clinical scenario and local resistance patterns.
Key Points to Consider
- The combination of vancomycin and piperacillin-tazobactam is associated with an increased risk of AKI 2, 3, 4.
- Cefepime/taniborbactam has shown potent activity against a wide range of Gram-negative bacterial pathogens, including MDR Pseudomonas aeruginosa and carbapenem-resistant Enterobacterales 5.
- The choice of additional antibiotic(s) should be guided by the patient's clinical condition, suspected or confirmed pathogen, and local resistance patterns.