Criteria & Principles
Please see the attached PDF for interpretative analysis of ESBL organisms.
Usual Dose & Administration
Usual Adult Dose
3.375 g IV q8h (administer each dose over 4 hours)
Adjustment of Dose & Administration
Indication-Specific Adjustment
Loading doses: a 3.375 g to 4.5 g loading dose can be given over 0.5 hours. This approach may be particularly useful to achieve faster target attainment in immunocompromised patients or in patients with previously documented Pseudomonas organisms with higher MIC distribution. The optimal time to start the subsequent extended infusion is 4 hours later in patients with CrCl >20 mL/min and 8 hours later in patients with CrCl <20 mL/min. Of note, administering loading doses has not been shown to decrease mortality or time to clinical improvement compared to initiating therapy with an extended infusion.
Higher doses may be considered in select patients, such as cystic fibrosis patients, necrotizing skin infections or critically-ill ICU patients with a known susceptible pathogen not improving on 3.375 g IV q8h. In such special cases, piperacillin-tazobactam 4.5 g IV over 4hrs Q8h may be considered (in those with normal renal function)
Extended infusion is preferred at DRH. Patients with orders for PTZ for which a 4-hour infusion time may not be practical, may receive a traditional standard 30-minute infusion at the discretion of the physician and/or nursing staff. Clinical pharmacists should be contacted to assist with traditional infusion dosing. ** To avoid inappropriate ordering of q8 or q12h interval traditional infusion, a BPA will fire on pharmacist verification. See details in attachment section** Placing new lines to accommodate extended-infusion PTZ is discouraged.
The physical compatibility of vancomycin has been evaluated with both branded and generic piperacillin-tazobactam in concentrations typical for extended infusions. Vancomycin concentrations of less than or equal to 7 mg/mL were compatible using simulated Y-site administration with piperacillin-tazobactam 33.75 mg/mL up to 90 mg/mL At DRH, vancomycin peripheral line concentrations do not exceed 6 mg/mL whereas central line concentrations may be up to 10 mg/mL. Therefore, it can be recommended to Y-site peripheral concentration vancomycin with pip-tazo 3.375g or 4.5g to help resolve medication scheduling issues [Ref: O’Donnell JN, et al. Visual and absorbance analyses of admixtures containing vancomycin and piperacillin-tazobactam at commonly used concentrations. Am J Health-Syst Pharm 2016; 73: 241-6.]
Guidelines Update for Prolonged Infusion of BetaLactams https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2844
Renal Adjustment
| CrCl (infusion time) | |||
| >20 mL/min |
<=20 mL/min (including peritoneal or hemodialysis) |
CRRT | |
| Piperacillin-tazobactam standard dose | 3.375g q8h (4 hr) | 3.375g q12h (4 hr) | 3.375g q8h (4 hr) |
|
Cystic fibrosis (susceptible organisms; all indications except CNS) MDR Pseudomonas/Acinetobacter, susceptible to pip/tazo Necrotizing fasciitis |
4.5g q8h (4 hr) | 4.5g q12h (4 hr) | 4.5g q8h (4 hr) |
*piperacillin-tazobactam 4.5 g IV over 4hrs may be considered in select patients, such as cystic fibrosis patients, necrotizing skin infections or critically-ill ICU patients with a known susceptible pathogen not improving on 3.375 g IV q8h or with suspected augmented renal clearance.
Drug-Specific Information
Extended infusion piperacillin/tazobactam dosing was adopted into clinical practice at Duke Regional Hospital in 2011. Exceptions to extended infusion dosing and administration are pediatric patients, patients in the Emergency Department who have not yet been admitted and transferred to the floor, as well as patients receiving piperacillin/tazobactam for surgical prophylaxis in the OR and PACU areas. We also allow 30 minute infusions on Unit 73 to accomodate their PT/OT schedules. Ambulatory care clinics may also resort to traditional 30-min infusions upon the discretion of the physician or nursing staff.
The document "Justification and Protocol for Extended-Infusion Piperacillin/Tazobactam in Adult Patients at Duke Regional Hospital", including compatibility/incompatibility list, is attached.
The document "Protocol for Extended-Infusion Piperacillin/Tazobactam in Pediatric Patients at Duke University Hospital", including compatibility/incompatibility list, is also attached
The recently updated guidelines on prolonged beta-lactams is also attached. https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2844
General Notes
- Up to date cost information, click here
- IV antimicrobials outpatient (OPAT) dosing, click here
- Obesity dosing weight recommendations, click here
- Helpful drug-drug interaction check website here
- When dosing guidance is provided it is important to note the following:
Fixed (ie non weight-based) doses in adults are historically based on a 70 kg patient. Specific disease states or individual patients may warrant dosages that differ from the above recommendations. Since product-specific criteria for dose adjustment based on creatinine clearance exist, consult product information regarding specific recommendations for dosage adjustment based on estimated creatinine clearance.