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Vancomycin-PipTaz Synergistic Nephrotoxicity — SCE Infectious Diseases MCQ

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HardAntimicrobial StewardshipVancomycin-PipTaz Synergistic NephrotoxicitySCE Infectious Diseases

A 55-year-old man with MRSA endocarditis develops acute kidney injury (creatinine rises from 90 to 280 µmol/L) while on IV Vancomycin. He is also receiving Piperacillin/Tazobactam for concurrent intra-abdominal sepsis. What is the most likely cause of his AKI?

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Correct answer: E — Vancomycin-Piperacillin/Tazobactam synergistic nephrotoxicity — this combination has significantly higher AKI rates than either drug alone

The combination of Vancomycin plus Piperacillin/Tazobactam has been associated with significantly higher rates of AKI compared to Vancomycin alone or Vancomycin plus Cefepime (multiple meta-analyses, including data from >25,000 patients). The mechanism is incompletely understood but may involve acute interstitial nephritis. When both Gram-positive AND Gram-negative cover is needed, Vancomycin plus Cefepime or Vancomycin plus Meropenem are preferred combinations to reduce nephrotoxicity risk. If Piperacillin/Tazobactam must be used with Vancomycin, intensive renal monitoring is essential.

Reference: BSAC 2023 – TDM; JAMA 2022 – Vanc/PipTaz nephrotoxicity meta-analysis; BNF 2024