Washington University Emergency Medicine Journal Club- November 2023


You are working a shift in the ED one afternoon when you encounter Mr. P, a 58-year-old male with insulin dependent diabetes, hypertension, and peripheral arterial disease. He underwent a left transmetatarsal amputation about 6 months previously due to a severe infection that began in his great toe. He presents today for a “wound check.” He has a large, nonhealing ulcer to his right lateral great toe which has now led to swelling and erythema of the entire foot. He has foul-smelling purulent drainage and you think you can see bone in the wound. He is afebrile but has a WBC of 16K, elevated ESR and CRP, and an x-ray showing signs of osteomyelitis involving the head of the head of the first metatarsal. 

You plan to admit the patient and order a dose of IV vancomycin and IV Zosyn for broad-spectrum coverage. You admit the patient to medicine and get a medicine from the medicine triage attending asking you to switch the order to vancomycin, cefepime, and metronidazole given the increased risk of kidney injury with vancomycin and Zosyn. You remember reading a write-up on this topic on the EMCrit website and wonder if there is any new evidence to support or refute the claim that vancomycin and Zosyn increase the risk of developing an acute kidney injury. You go online and being your search… 

PICO Question


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Article 1: Qian ET, Casey JD, Wright A, Wang L, Shotwell MS, Siemann JK, Dear ML, Stollings JL, Lloyd BD, Marvi TK, Seitz KP, Nelson GE, Wright PW, Siew ED, Dennis BM, Wrenn JO, Andereck JW, Han JH, Self WH, Semler MW, Rice TW; Vanderbilt Center for Learning Healthcare and the Pragmatic Critical Care Research Group. Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA. 2023 Oct 24;330(16):1557-1567. doi: 10.1001/jama.2023.20583. PMID: 37837651; PMCID: PMC10576861. Answer Key

Article 2: Gomes DM, Smotherman C, Birch A, Dupree L, Della Vecchia BJ, Kraemer DF, Jankowski CA. Comparison of acute kidney injury during treatment with vancomycin in combination with piperacillin-tazobactam or cefepime. Pharmacotherapy. 2014 Jul;34(7):662-9. doi: 10.1002/phar.1428. Epub 2014 Apr 18. PMID: 24753221. Answer Key.

Article 3: Miano TA, Hennessy S, Yang W, Dunn TG, Weisman AR, Oniyide O, Agyekum RS, Turner AP, Ittner CAG, Anderson BJ, Wilson FP, Townsend R, Reilly JP, Giannini HM, Cosgriff CV, Jones TK, Meyer NJ, Shashaty MGS. Association of vancomycin plus piperacillin-tazobactam with early changes in creatinine versus cystatin C in critically ill adults: a prospective cohort study. Intensive Care Med. 2022 Sep;48(9):1144-1155. doi: 10.1007/s00134-022-06811-0. Epub 2022 Jul 14. PMID: 35833959; PMCID: PMC9463324. Answer Key.

Article 4: Chen AY, Deng CY, Calvachi-Prieto P, Armengol de la Hoz MÁ, Khazi-Syed A, Chen C, Scurlock C, Becker CD, Johnson AEW, Celi LA, Dagan A. A Large-Scale Multicenter Retrospective Study on Nephrotoxicity Associated With Empiric Broad-Spectrum Antibiotics in Critically Ill Patients. Chest. 2023 Aug;164(2):355-368. doi: 10.1016/j.chest.2023.03.046. Epub 2023 Apr 9. PMID: 37040818; PMCID: PMC10475819. Answer Key.

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