Abstract
Aim
The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury (AKI), leading to propose cefepim as an alternative since 2017 in our reference center. The present study compared microbiological efficacy and tolerance of these two EAT strategies.
Method
All patients with PJI empirically treated by vancomycin-cefepim (n=90) were prospectively enrolled in an observational study, and compared with vancomycin-piperacillin/tazobactam-treated historical controls (n=117), regarding: i) the proportion efficacious empirical regimen (i.e., at least one of the two molecules active against the identified organism(s) based on in vitro susceptibility testing); and ii) the incidence of empirical therapy-related adverse events (AE), classified according to the Common terminology criteria for AE (CTCAE).
Results
Among the 146 (67.3%) documented infections, the EAT was considered as efficacious in 99 (99.0%) and 66 (98.5%) in the piperacillin-tazobactam and cefepim-treated patients, respectively (p=0.109). The rate of adverse events, and in particular AKI, was significantly higher in the vancomycin-piperacillin/tazobactam (n=38 [32.5%] and 32 [27.6%]) compared to the vancomycin-cefepim (n=13 [14.4%] and 5 [5.7%]) group (p=0.003 and <0.001, respectively). Of note, sex, age, and the proportion of patients receiving other nephrotoxics were similar among piperacillin/tazobactam- and cefepim-treated patients. However, in comparison with patients receiving cefepim, a higher modified Charlson's comorbitidy index (4 [IQR, 3–5] versus 2 [IQR, 2–4], p<0.001) has to be acknowledged, mainly related to a higher prevalence of baseline chronic renal injury (n=62, 53.4% versus n=34, 38.6%; p=0.035).
Conclusions
The empirical use of vancomycin-cefepim in PJI was as efficient as vancomycin-piperacillin/tazobactam, and was associated with a significantly lower incidence of AKI.
