Zosyn extended infusion policy

[Pharmist1720]

We started a new Zosyn extended infusion policy at our hospital and the doctors/nurses are flipping out about it. All I've heard is how we're "killing kidneys". Our protocol is:
Zosyn 4.5g IV over 30 minutes loading dose x 1
Zosyn 3.375 IV over 3hrs q6h for CrCl >40
Zosyn 2.25 IV over 3hrs q6h for CrCl 20-40
Zosyn 2.25 IV over 3 hours for CrCl <20, PD, or HD

What's everybody else's protocol? And have you gotten any pushback?

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[njac]

1st dose 4.5gm over 30min

CrCl > 20 mL/min = 3.375gm Q8H, infuse each dose over 4 hours

CrCl <20 mL/min = 4.5gm Q12H, infuse each dose over 30 minutes.

This was implemented 4 or 5 years ago with little pushback.

The big concern was tying up a line, but we put these doses in 100mL of NS, and at that concentration it is compatible with vanco, so that ameliorated a lot of compatability concerns.

 

[bacillus1]

No load

CrCl>100: 4.5g q6 (I believe over 3 hours, but we hardly use this dose in anyone, so I'd have to double check)
CrCl 20-100: 3.375g q8 over 4 hours (seems like this dose is where most of the data is)
CrCl<20 or dialysis: no extended infusion, use 3.375g q12 over 30 minutes

 

[El Trombopag]

I don't see how giving less drug overall, as well as lower peak serum levels, can be interpreted as 'killing the kidneys'.

 

[Dred Pirate]

no load
ZOsyn 3.375 gm IV q 8 h over 4 hours if CrCl >20
CrCl < 20 3.375 gm IV q 12 h over 4 hours

we have saived over 60k last year alone, decreased the resistance paterns, etc.

the concept of killing kidneys is absolute ridiculous - less drug = no increased renal damage

The real issue is resistence and cost savings, zosyn really doesn't have much of a renal insult (unless you are running with vanc but that is likely due to the fact that hospitals were mixing vanc in D5W and not knowing it is incompatible with Zosyn unless you mix it in NS.

 

[sakigt]

Biggest pushback we had were IV compatibility issues, especially vanco (i know theres controversy about this)

No load, ED 1st dose can be run over a half hour
>20 ml/min or CVVHD : 4.5 q8/4hrs or 3.375g q8/4hrs
< 20 ml/min or HD : 3.375g q12/4hrs

 

[Dred Pirate]

Biggest pushback we had were IV compatibility issues, especially vanco (i know theres controversy about this)

No load, ED 1st dose can be run over a half hour
>20 ml/min or CVVHD : 4.5 q8/4hrs or 3.375g q8/4hrs
< 20 ml/min or HD : 3.375g q8/4hrs

from what I know - Vanc in D5w - not compatible, in NS = compatible

 

[njac]

Why infuse the dose over 4 hours in CrCl <20 or HD?

Don't these patients essentially "auto-extended infuse" their dose by not clearing it?

 

[Dred Pirate]

Why infuse the dose over 4 hours in CrCl <20 or HD?

Don't these patients essentially "auto-extended infuse" their dose by not clearing it?

agreed- for merrem - we go back to the 1 hour infusion in these patients - others we do over 3 hours

 

[bacillus1]

Biggest pushback we had were IV compatibility issues, especially vanco (i know theres controversy about this)

If someone is started on vanc and zosyn, we just retime the orders so they are not scheduled to be infused at the same time. Q8 zosyn can be retimed as TID with custom administration times as long as 2 consecutive doses are not spaced by more than 12 hours

 

[sakigt]

Why infuse the dose over 4 hours in CrCl <20 or HD?

Don't these patients essentially "auto-extended infuse" their dose by not clearing it?

Doh! q12 not q8, my bad, corrected in the OP.

 

[VCU07]

Why infuse the dose over 4 hours in CrCl <20 or HD?

Don't these patients essentially "auto-extended infuse" their dose by not clearing it?

We do 3.375 q8/4hrs. One problem with selectively doing EI dosing in certain populations is inconsistency. For us, it was all or none. There would have been so much confusion on when to and when not to (and having the RNs remember this) that I think it increases the chances for errors and failures.

 

[bacillus1]

We do 3.375 q8/4hrs. One problem with selectively doing EI dosing in certain populations is inconsistency. For us, it was all or none. There would have been so much confusion on when to and when not to (and having the RNs remember this) that I think it increases the chances for errors and failures.

We have an autoconversion policy per pharmacy. RN doesn't need to remember; he or she can just read the IV label. Most of the time RNs don't know infusion times off the top of their head.

 

[VCU07]

We have an autoconversion policy per pharmacy. RN doesn't need to remember; he or she can just read the IV label. Most of the time RNs don't know infusion times off the top of their head.

I disagree somewhat here. Our RNs, esp my critical care ones know them off the top of their heads. We did it the way we did for simplicity sake.