piperacillin (Rx)

Brand and Other Names:Pipracil
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

powder for injection

  • 2g
  • 3g
  • 4g
  • 40g

Usual Dosage Range

IV: 3-4 g/dose q4-6hr; not to exceed 24 g/24hr

IM: 2-3 g/dose q6-12hr; not to exceed 24 g/24 hr

Urinary Tract, Uncomplicated

6-8 g/day IV/IM (100 to 125 mg/kg/day) divided q6-12 hr  

Community-Acquired Pneumonia

6-8 g/day IV/IM (100 to 125 mg/kg/day) divided q6-12 hr  

Acute Cholangitis

4 g IV q6hr

Moderate Infections

2-3 g/dose IV/IM q6-12hr; not to exceed 2 g IM/site

Severe Infections

3-4 g IV/IM q4-6hr; not to exceed 24 g/24 hr

Uncomplicated Gonorrhea

2 g once with 1 g probenecid 30 min before injection

Pseudomonas Infections

4 g IV/IM q4hr

Renal Impairment

CrCl 20-40 mL/min: 3-4 g q8hr

CrCl <20 mL/min: 3-4 g q12hr

Other Indications & Uses

Extended spectrum: Acinetobacter spp., Alcaligenes xylosoxidans, Bacteroides spp., Citrobacter diversus, Citrobacter freundii, E. coli, Fusobacteriae, H. influenzae, Klebsiella spp., N. gonorrhoeae, Peptococcus spp., Peptostreptococcus spp., indole-pos. Proteus spp., Providencia spp., Pseudomonas spp., Serratia spp., Streptococcus faecalis, Yersinia enterolitica

Dosage Forms & Strengths

powder for injection

  • 2g
  • 3g
  • 4g
  • 40g

Usual Dosage Range

Neonates: 100 mg/kg IV/IM q12hr  

Infants and Children: 200-300 mg/kg/day IV/IM divided q4-6hr

Cystic Fibrosis

350-500 mg/kg/day IV/IM divided q4-6hr  

Adjust dose for renal impairment

Usual dosage range

IV: 2-4 g q6-8hr

IM: 1-2 g q8-12hr

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Interactions

Interaction Checker

and piperacillin

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (0)

              Serious - Use Alternative (12)

              • antithrombin alfa

                piperacillin increases effects of antithrombin alfa by pharmacodynamic synergism. Avoid or Use Alternate Drug.

              • antithrombin III

                piperacillin increases effects of antithrombin III by pharmacodynamic synergism. Avoid or Use Alternate Drug.

              • argatroban

                piperacillin will increase the level or effect of argatroban by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

              • BCG vaccine live

                piperacillin decreases effects of BCG vaccine live by pharmacodynamic antagonism. Contraindicated. Wait until antibiotic treatment complete to administer live bacterial vaccine; antibiotics may diminish therapeutic effects of BCG.

              • bivalirudin

                piperacillin will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

              • cholera vaccine

                piperacillin, cholera vaccine. pharmacodynamic antagonism. Avoid or Use Alternate Drug. Avoid coadministration of cholera vaccine with systemic antibiotics since these agents may be active against the vaccine strain. Do not administer cholera vaccine to patients who have received oral or parenteral antibiotics within 14 days prior to vaccination.

              • dalteparin

                piperacillin increases effects of dalteparin by anticoagulation. Avoid or Use Alternate Drug. Piperacillin can inhibit platelet aggregation.

              • enoxaparin

                piperacillin increases effects of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. Piperacillin can inhibit platelet aggregation.

              • heparin

                piperacillin will increase the level or effect of heparin by anticoagulation. Avoid or Use Alternate Drug. piperacillin can inhibit platelet aggregation

              • omadacycline

                omadacycline decreases effects of piperacillin by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Tetracyclines may interfere with the bactericidal action of penicillins. Monitor for decreased therapeutic effects of penicillins if concomitantly used with a tetracycline.

              • sarecycline

                sarecycline decreases effects of piperacillin by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Tetracyclines may interfere with the bactericidal action of penicillins. Monitor for decreased therapeutic effects of penicillins if concomitantly used with a tetracycline.

              • warfarin

                piperacillin increases effects of warfarin by anticoagulation. Avoid or Use Alternate Drug. Piperacillin can inhibit platelet aggregation.

              Monitor Closely (17)

              • azithromycin

                azithromycin decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • bazedoxifene/conjugated estrogens

                piperacillin will decrease the level or effect of bazedoxifene/conjugated estrogens by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • chloramphenicol

                chloramphenicol decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • clarithromycin

                clarithromycin decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • demeclocycline

                demeclocycline decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • dichlorphenamide

                dichlorphenamide and piperacillin both decrease serum potassium. Use Caution/Monitor.

              • doxycycline

                doxycycline decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • erythromycin base

                erythromycin base decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • erythromycin ethylsuccinate

                erythromycin ethylsuccinate decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • erythromycin lactobionate

                erythromycin lactobionate decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • erythromycin stearate

                erythromycin stearate decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • minocycline

                minocycline decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • probenecid

                probenecid will increase the level or effect of piperacillin by acidic (anionic) drug competition for renal tubular clearance. Use Caution/Monitor.

              • sodium picosulfate/magnesium oxide/anhydrous citric acid

                piperacillin decreases effects of sodium picosulfate/magnesium oxide/anhydrous citric acid by altering metabolism. Use Caution/Monitor. Coadministration with antibiotics decreases efficacy by altering colonic bacterial flora needed to convert sodium picosulfate to active drug.

              • tetracycline

                tetracycline decreases effects of piperacillin by pharmacodynamic antagonism. Use Caution/Monitor. bacteriostatic agents may inhibit the effects of bactericidal agents.

              • vancomycin

                piperacillin increases toxicity of vancomycin by unspecified interaction mechanism. Use Caution/Monitor. Monitor kidney function in patients concomitantly administered with piperacillin and vancomycin.

              • vecuronium

                piperacillin increases toxicity of vecuronium by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Neuromuscular blockade may be prolonged.

              Minor (15)

              • amikacin

                piperacillin increases effects of amikacin by pharmacodynamic synergism. Minor/Significance Unknown.

              • aspirin

                piperacillin, aspirin. Either increases effects of the other by receptor binding competition. Minor/Significance Unknown. Salicylic acid could be displaced from protein binding sites or it could itself displace other protein-bound drugs and result in an enhanced effect of the displaced drug.

              • aspirin rectal

                piperacillin will increase the level or effect of aspirin rectal by plasma protein binding competition. Minor/Significance Unknown. Salicylic acid could be displaced from protein binding sites or it could itself displace other protein-bound drugs and result in an enhanced effect of the displaced drug

              • aspirin/citric acid/sodium bicarbonate

                piperacillin will increase the level or effect of aspirin/citric acid/sodium bicarbonate by plasma protein binding competition. Minor/Significance Unknown. Salicylic acid could be displaced from protein binding sites or it could itself displace other protein-bound drugs and result in an enhanced effect of the displaced drug

              • chlorothiazide

                chlorothiazide increases levels of piperacillin by decreasing renal clearance. Minor/Significance Unknown.

              • choline magnesium trisalicylate

                piperacillin will increase the level or effect of choline magnesium trisalicylate by acidic (anionic) drug competition for renal tubular clearance. Minor/Significance Unknown. Salicylate saltscould be displaced from binding sites or could displace other highly protein-bound drugs such as penicillins

              • gentamicin

                piperacillin increases effects of gentamicin by pharmacodynamic synergism. Minor/Significance Unknown.

              • hydrochlorothiazide

                hydrochlorothiazide increases levels of piperacillin by decreasing renal clearance. Minor/Significance Unknown.

              • ibuprofen IV

                piperacillin will increase the level or effect of ibuprofen IV by acidic (anionic) drug competition for renal tubular clearance. Minor/Significance Unknown.

              • meclofenamate

                piperacillin will increase the level or effect of meclofenamate by acidic (anionic) drug competition for renal tubular clearance. Minor/Significance Unknown.

              • neomycin PO

                piperacillin increases effects of neomycin PO by pharmacodynamic synergism. Minor/Significance Unknown.

              • rose hips

                rose hips will increase the level or effect of piperacillin by acidic (anionic) drug competition for renal tubular clearance. Minor/Significance Unknown.

              • streptomycin

                piperacillin increases effects of streptomycin by pharmacodynamic synergism. Minor/Significance Unknown.

              • tobramycin

                piperacillin increases effects of tobramycin by pharmacodynamic synergism. Minor/Significance Unknown.

              • willow bark

                piperacillin will increase the level or effect of willow bark by acidic (anionic) drug competition for renal tubular clearance. Minor/Significance Unknown.

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              Adverse Effects

              <1%

              Seizure

              Rash

              Hemolytic anemia

              Postive Coombs reaction

              Prolonged prothrombin time

              Interstitial nephritis

              Hypersensitivity

              Anaphylaxis

              Thrombophlebitis

              Injection site pain

              Headache

              Fever

              Intestinal infection due to pseudomonas

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              Warnings

              Contraindications

              Allergy to penicillins, cephalosporins, imipenem

              Cautions

              Risk of bleeding complications, especially in renal impairment

              Monitor renal, hepatic & especially hematopoietic functions during prolonged treatment

              Hypersensitivity reactions reported; discontinue therapy and institute appropriate therapy if allergic reaction occurs

              Found to be an independent risk factor for renal failure and was associated with delayed recovery of renal function as compared to other beta-lactam antibacterial drugs; if alternative treatment options are inadequate or unavailable, monitor renal function during treatment

              Combined use of piperacillin/tazobactam and vancomycin may be associated with an increased incidence of acute kidney injury

              Serious skin reactions, including toxic epidermal necrolysis and Stevens-Johnson syndrome, acute exanthematous pustulosis, and drug reaction with eosinophilia and systemic symptoms (DRESS) reported; monitor closely if rash develops; discontinue if lesions progress

              Hematological effects (including bleeding, leukopenia and neutropenia) have occurred.

              Monitor hematologic tests during prolonged therapy

              Use may result in fungal or bacterial superinfection; valuate patients for Clostridium difficile if diarrhea occurs

              Dosage adjustment recommended in patients with renal impairment or receiving hemodialysis

              Use with caution in patients with history of seizure disorder; high levels, that may result from renal impairment, may increase risk of seizures

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              Pregnancy & Lactation

              Pregnancy

              Piperacillin and tazobactam cross the placenta in humans; however, there are insufficient data in pregnant women to inform a drug-associated risk for major birth defects and miscarriage; no fetal structural abnormalities observed in rats or mice when piperacillin/tazobactam was administered intravenously during organogenesis at doses 1 to 2 times and 2 to 3 times human dose, respectively, based on body-surface area’ however, fetotoxicity in presence of maternal toxicity was observed in developmental toxicity and peri/postnatal studies conducted in rats (intraperitoneal administration prior to mating and throughout gestation or from gestation day 17 through lactation day 21) at doses less than the maximum recommended human daily dose based on body-surface area

              Lactation

              Piperacillin is excreted in human milk; tazobactam concentrations in human milk not studied; no information available on effects of piperacillin and tazobactam on breastfed child or on milk production; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed child from therapy or from underlying maternal condition.

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Inhibits biosynthesis of cell wall mucopeptides and stage of active multiplication; has antipseudomonal activity

              Pharmacokinetics

              Half-Life: 36-80 min, dose dependent, higher in renal insufficiency

              Protein Bound: 16%

              Absorption: 70-80% (IM)

              Peak Plasma Time: 30-50 min (IM)

              Absorption: 70-80% (IM)

              Distribution: Crosses placenta

              Metabolism: Liver

              Excretion: Urine (primarily); feces (partially)

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              Administration

              IV Compatibilities

              Solution: compatible with common solvents

              Additive: clindamycin, flucloxacillin, fluconazole, hydrocortisone, linezolid, ofloxacin, KCl, verapamil

              Syringe: heparin

              Y-site (partial list): allopurinol, bivalirudin, ciprofloxacin, diltiazem, esmolol, famotidine, heparin, hydromorphone, linezolid, lorazepam, magnesium sulfate, meperidine, midazolam, morphine, ranitidine, verapamil, zidovudine

              IV Incompatibilities

              Solution: aminoglycosides

              Additive: aminoglycosides, ciprofloxacin

              Y-site: aminoglycosides, amiodarone, amphotericin B cholesteryl SO4, cisatracurium(?), filgrastim, fluconazole, gatifloxacin, gemcitabine, ondansetron, sargramostim, vinorelbine

              IV/IM Preparation

              IV: reconstitute each gram w/ 5 mL SWI, BWI, NS, D5W or other compatible diluents

              Slight darkening does not indicate potency loss

              IV/IM Administration

              Slow direct inj over 3-5 min, OR

              Intermittent infusion in at least 50 mL over 20-30 min

              IM: upper outer quadrant of buttock

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              Formulary

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              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.