Clinical question: Are there increased adverse outcomes with the utilization of cefepime or piperacillin-tazobactam?
Background: Hospitalists frequently prescribe cefepime or piperacillin-tazobactam for antipseudomonal coverage. There have been reports stating that there is an increased incidence of change in mental status in the use of cefepime. There have been studies indicating a possible association of acute kidney injury with piperacillin-tazobactam specifically when used concurrently with vancomycin.
Study design: 1:1 matched randomization
Setting: Emergency department, medical inpatient unit, or ICU at one U.S. hospital.
Synopsis: This study analyzed 2,511 patients over the age of 18 prescribed antipseudomonal antibiotics from November 10, 2021, to October 7, 2022, in the emergency department, medical inpatient unit, or ICU at Vanderbilt University Medical Center in Nashville, Tenn. The patient population had a median age of 58 years with 42.7% being female. The primary outcome was acute kidney injury (AKI) or death within 14 days. Secondary outcomes were major adverse kidney events and number of days alive free of delirium or coma within the 14 days. After the patients were randomized to a 1:1 ratio, the patient was provided the antibiotic and the clinician decided on the duration of treatment.
There was no difference noted between the cefepime and piperacillin-tazobactam groups for death or the highest stage of AKI by the 14th day. [OR, 0.95; 95% CI, 0.80 to 1.13), P=.56] The cefepime group experienced fewer days alive and increased days with delirium and coma as compared with the piperacillin-tazobactam group within the first 14 days (11.9 days versus 12.2 days; OR, 0.79; 95% CI, 0.65 to 0.95).
Bottom line: Piperacillin-tazobactam did not show an increased rate of AKI as compared to cefepime. Cefepime had an increased number of days with delirium, coma, and death within 14 days as compared to piperacillin-tazobactam. Limitations include the patient receiving antibiotics for only a median duration of three days and that the study was comparing between only two antibiotics.
Citation: Qian ET, et al. Cefepime vs piperacillin-tazobactam in adults hospitalized with acute infection The ACORN randomized clinical trial. JAMA. 2023;330(16):1557-67.
Dr. Huang
Dr. Huang is the specialty medical director at Advocate Health, and an associate professor of internal medicine, at Wake Forest School of Medicine, both in Winston-Salem, N.C. Disclosure: Dr. Huang is on the scientific advisory board for Medicus Tek and is a hospital medicine editor for Dynamed/EBSCO.