Opinion: vancomycin + cefepime + metronidazole (VCM) is superior empiric therapy than vancomycin + piperacillin/tazobactam (VPT) for *most* indications in the emergency department.
There are five reasons why I believe this to be true. #inthisessayiwill
There are five reasons why I believe this to be true. #inthisessayiwill
Empiric regimen selection for patients with healthcare-associated risk factors is tough.
Despite my bias, I hope to generate more thought in your next decision rather than simply saying....
Despite my bias, I hope to generate more thought in your next decision rather than simply saying....
1️⃣ VCM is more thoughtful than VPT.
Need anaerobic coverage? Add it! If you don’t, you’re not stuck with broader than necessary therapy.
Don’t need PsAr coverage? Drop to ceftriaxone.
VCM also allows for easier tailoring of therapy later during admission.
Need anaerobic coverage? Add it! If you don’t, you’re not stuck with broader than necessary therapy.
Don’t need PsAr coverage? Drop to ceftriaxone.
VCM also allows for easier tailoring of therapy later during admission.
2️⃣ C typically covers SPACE bacteria better than PT.*
While PT has some activity against ESBLs, for *most* ESBLs a carbapenem will likely be utilized for empiric therapy in patients with a history of ESBL.
*Always consult your hospital’s antibiogram.
While PT has some activity against ESBLs, for *most* ESBLs a carbapenem will likely be utilized for empiric therapy in patients with a history of ESBL.
*Always consult your hospital’s antibiogram.
3️⃣ CM provides better anaerobic coverage than PT.
Studies showed adding M to PT for additional anaerobic coverage in intra-abdominal infections is both redundant and inferior to combinations with CM.
Studies showed adding M to PT for additional anaerobic coverage in intra-abdominal infections is both redundant and inferior to combinations with CM.
4️⃣ VCM has more useful tissue penetration in nosocomial infections than VPT.
PT *DOES NOT* penetrate the CNS. If CNS is missed as a source in the differential, patients will have a significant coverage gap.
C has better penetration to lung AND bone than PT(‼️).
PT *DOES NOT* penetrate the CNS. If CNS is missed as a source in the differential, patients will have a significant coverage gap.
C has better penetration to lung AND bone than PT(‼️).
5️⃣ VCM results in less AKI than VPT.
Critically ill patients with healthcare-associated risk factors commonly present or develop AKI during hospitalization.
Combinations including VPT can further increase the chance of AKI in these patients.
Critically ill patients with healthcare-associated risk factors commonly present or develop AKI during hospitalization.
Combinations including VPT can further increase the chance of AKI in these patients.
Some potential downsides to a VCM regimen:
1. Greater incidence of Cdiff
2. No Enterococcus coverage
3. Cefepime-associated neurotoxicity (very rare)
1. Greater incidence of Cdiff
2. No Enterococcus coverage
3. Cefepime-associated neurotoxicity (very rare)
As in most cases, keeping patient-specific factors in mind are important in any treatment decision and will likely lead to the best course of action.
Please feel free to chime in, disagree, post literature, and share your perspectives 💊
Please feel free to chime in, disagree, post literature, and share your perspectives 💊
