Zosyn
piperacillin sodium and tazobactam sodium
Pharmacologic class: Penicillin (extended-spectrum), beta-lactamase inhibitor
Therapeutic class: Anti-infective
Pregnancy risk category B
Action
Piperacillin inhibits bacterial cell-wall synthesis, resulting in cell death. Tazobactam increases piperacillin efficacy.
Availability
Powder for injection: 2 g piperacillin and 0.25 g tazobactam/vial, 3 g piperacillin and 0.375 g tazobactam/vial, 4 g piperacillin and 0.5 g tazobactam/vial
Indications and dosages
➣ Community-acquired pneumonia; ruptured appendix; peritonitis; pelvic inflammatory disease; skin and skin-structure infections
Adults and children older than age 12: 3.375 g (3 g piperacillin and 0.375 g tazobactam) I.V. q 6 hours for 7 to 10 days
➣ Nosocomial pneumonia
Adults and children ages 12 and older: 3.375 g (3 g piperacillin and 0.375 g tazobactam) I.V. over 30 minutes q 4 hours for 7 to 14 days, given with an aminoglycoside
Dosage adjustment
• Renal impairment
Contraindications
• Hypersensitivity to penicillins, cephalosporins, imipenems, or beta-lactamase inhibitors
• Neonates
Precautions
Use cautiously in:
• heart failure, renal insufficiency (in children), seizures, bleeding disorders, uremia, hypokalemia, cystic fibrosis
• patients with sodium restrictions
• pregnant or breastfeeding patient
• children younger than age 12 (safety and efficacy not established).
Administration
• Ask patient about allergy to penicillins, cephalosporins, imipenems, or beta-lactamase inhibitors before giving.
• Dilute each gram with 5 ml of diluent, such as sterile or bacteriostatic water for injection, normal saline solution for injection, dextrose 5% in water, dextrose 5% in normal saline solution for injection, or 6% dextran in normal saline solution. Don't use lactated Ringer's solution.
• Shake vial until drug dissolves. Dilute again to a final volume of 50 ml; infuse over 30 minutes.
• Don't mix with other drugs. If possible, stop primary infusion while piperacillin infuses.
• Don't mix in same container with aminoglycosides, which are chemically incompatible with piperacillin.
Adverse reactions
CNS: headache, insomnia, agitation, dizziness, anxiety, lethargy, hallucinations, depression, twitching, coma, seizures
CV: hypertension, chest pain, tachycardia
EENT: rhinitis, glossitis
GI: nausea, vomiting, diarrhea, constipation, dyspepsia, abdominal pain, pseudomembranous colitis
GU: proteinuria, hematuria, vaginal candidiasis, vaginitis, oliguria, interstitial nephritis, glomerulonephritis
Hematologic: anemia, increased bleeding, bone marrow depression, leukopenia, thrombocytopenia
Metabolic: hypokalemia, hypernatremia
Respiratory: dyspnea
Skin: rash, pruritus
Other: fever; pain, edema, inflammation, or phlebitis at I.V. site; superinfection; hypersensitivity reactions including serum sickness and anaphylaxis
Interactions
Drug-drug. Aminoglycosides: aminoglycoside inactivation
Aspirin, probenecid: increased piperacillin blood level
Hormonal contraceptives: decreased contraceptive efficacy
Methotrexate: increased risk of methotrexate toxicity
Tetracyclines: decreased piperacillin efficacy
Vecuronium: prolonged neuromuscular blockade
Drug-diagnostic tests. Coombs' test, urine glucose tests using copper reduction method (Clinitest, Benedict's or Fehling's solution), urine protein: false-positive results
Eosinophils: increased count
Granulocytes, hemoglobin, platelets, white blood cells: decreased levels
Patient monitoring
• Assess neurologic status, especially for seizures.
• Monitor vital signs and fluid intake and output.
• Evaluate electrolyte levels, CBC with white cell differential, and culture and sensitivity tests. Watch for evidence of hypokalemia and blood dyscrasias.
• In patients receiving high doses or prolonged therapy, monitor for signs and symptoms of bacterial or fungal superinfection and pseudomembranous colitis.
• Monitor patient's dietary sodium intake (drug has high sodium content).
See Immediately report rash, hives, severe diarrhea, black tongue, sore throat, fever, or unusual bleeding or bruising.
Patient teaching
• Tell patient to monitor urinary output and report significant changes.
• Instruct patient to report unusual pain, redness, swelling, or other changes at infusion site.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
piperacillin/tazobactam
(pi-per-a-sill-in/tay-zoe-bak-tam) piperacillintazobactam,Tazocin
(trade name),Zosyn
(trade name)Classification
Therapeutic: anti infectivesPharmacologic: extended spectrum penicillins
Indications
Action
Therapeutic effects
- Bacteroides fragilis,
- E. coli,
- Acinetobacter baumanii,
- Klebsiella pneumoniae,
- Pseudomonas aeruginosa,
- Staphylococcus aureus,
- Haemophilus influenzae.
Pharmacokinetics
Time/action profile (piperacillin blood levels)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| IV | rapid | end of infusion | 4–6 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- seizures (higher doses) (life-threatening)
- confusion
- dizziness
- headache
- insomnia
- lethargy
Gastrointestinal
- pseudomembranous colitis (life-threatening)
- diarrhea (most frequent)
- constipation
- drug-induced hepatitis
- nausea
- vomiting
Genitourinary
- interstitial nephritis
Dermatologic
- stevens-johnson syndrome (life-threatening)
- toxic epidermal necrolysis (life-threatening)
- rashes (↑ in cystic fibrosis patients) (most frequent)
- urticaria
Hematologic
- bleeding
- leukopenia
- neutropenia
- thrombocytopenia
Local
- pain (most frequent)
- phlebitis at IV site (most frequent)
Miscellaneous
- hypersensitivity reactions, including anaphylaxis and serum sickness (life-threatening)
- fever (↑ in cystic fibrosis patients)
- superinfection
Interactions
Drug-Drug interaction
Probenecid ↓ renal excretion and ↑ blood levels.May alter excretion of lithium.Potassium-losing diuretics, corticosteroids, or amphotericin B may ↑ risk of hypokalemia.↑ risk of hepatotoxicity with other hepatotoxic agents.May ↓ levels/effects of aminoglycosides in patients with renal impairment.May ↑ levels and risk of toxicity from methotrexate.Route/Dosage
Contains 2.79 mEq (64 mg) sodium/g of piperacillin; adult doses below expressed as combined piperacillin/tazobactam contentRenal Impairment
Intravenous (Adults) CCr 20–40 mL/min—2.25 g q 6 hr (3.375 g q 6 hr for nosocomial pneumonia); CCr <20 mL/min—2.25 g q 8 hr (2.25 g q 6 hr for nosocomial pneumonia); Hemodialysis—2.25 g q 12 h (2.25 g q 8 hr for nosocomial pneumonia).Availability (generic available)
Nursing implications
Nursing assessment
- Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy.
- Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.
- Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.
- Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
- Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.
- Assess for skin reactions (rash, fever, edema, mucosal erosions or ulcerations, red or inflamed eyes). Monitor patient with mild to moderate rash for progression. If rash becomes severe or systemic symptoms occur, discontinue piperacillin/tazobactam.
- Lab Test Considerations: Evaluate renal and hepatic function, CBC, serum potassium, and bleeding times prior to and routinely during therapy.
- May cause positive direct Coombs’ test result.
- May cause ↑ BUN, creatinine, AST, ALT, serum bilirubin, alkaline phosphatase, and LDH.
- May cause leukopenia and neutropenia, especially with prolonged therapy or hepatic impairment.
- May cause prolonged prothrombin and partial thromboplastin time.
- May cause ↓ hemoglobin and hematocrit and thrombocytopenia, eosinophilia, leukopenia, and neutropenia. It also may cause proteinuria; hematuria; pyuria; hyperglycemia; ↓ total protein or albumin; and abnormalities in sodium, potassium, and calcium levels.
Potential Nursing Diagnoses
Risk for infection (Indications, Side Effects)Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Implementation
Intravenous Administration
- pH: 4.5–6.8.
- Intermittent Infusion: Reconstitute each 1 g of piperacillin with at least 5 mL of 0.9% NaCl, sterile water for injection, or D5W. Diluent: Dilute further in 50–100 mL of 0.9% NaCl, D5W, D5/0.9% NaCl, or LR. Reconstituted vials stable for 24 hr at room temperature or 48 hr if refrigerated. Infusion stable for 24 hr at room temperature or 7 days if refrigerated.
- Rate: Infuse over 30 min.
- Y-Site Compatibility: alfentanil, allopurinol, amifostine, aminocaproic acid, aminophylline, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, busulfan, butorphanol, calcium acetate, calcium chloride, calcium gluconate, carboplatin, carmustine, cefepime, chloramphenicol, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, diazepam, digoxin, diphenhydramine, docetaxel, dopamine, doxacurium, enalaprilat, ephedrine, epinephrine, eptifibatide, erythromycin, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, floxuridine, fluconazole, fludarabine, fluorouracil, foscarnet, fosphenytoin, furosemide, granisetron, heparin, hetastarch, hydrocortisone, hydromorphone, ifosfamide, isoproterenol, ketamine, ketorolac, leucovorin calcium, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, mesna, metaraminol, methotrexate, methylprednisolone, metoclopramide, metoprolol, metronidazole, milrinone, morphine, naloxone, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxytocin, paclitaxel, palonosetron, pancuronium, pantoprazole, pemetrexed, pentobarbital, phenobarbital, phentolamine, phenylephrine, potassium acetate, potassium chloride, potassium phosphates, procainamide, ranitidine, remifentanil, rituximab, sargramostim, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiotepa, tigecycline, tirofiban, trimethoprim/sulfamethoxazole, vasopressin, vinblastine, vincristine, voriconazole, zidovudine, zoledronic acid
- Y-Site Incompatibility: acyclovir, alemtuzumab, amiodarone, amphotericin B cholesteryl, amphotericin B colloidal, azithromycin, caspofungin, chlorpromazine, ciprofloxacin, cisplatin, dacarbazine, dantrolene, daunorubicin, diltiazem, dobutamine, doxorubicin, doxorubicin liposome, doxycycline, droperidol, epirubicin, famotidine, ganciclovir, gemcitabine, glycopyrrolate, haloperidol, hydralazine, hydroxyzine, idarubicin, insulin, irinotecan, labetalol, levofloxacin, methyldopate, midazolam, mitomycin, mitoxantrone, nalbuphine, nesiritide, nicardipine, pentamidine, pentazocine, phenytoin, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, rocuronium, streptozocin, thiopental, tobramycin, tranexamic acid, trastuzumab, vecuronium, verapamil, vinorelbine
Patient/Family Teaching
- Advise patient to report rash and signs of superinfection (black furry overgrowth on tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy.
- Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.
Evaluation/Desired Outcomes
- Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection.