Zosyn Nursing Considerations

Last updated on November 29th, 2022 at 04:46 pm

Zosyn Nursing Implications

Zosyn (Piperacillin-Tazobactam) Nursing Pharmacology

The medication Zosyn, its generic name being piperacillin-tazobactam, is made of a combination of two antibiotics: piperacillin which is a penicillin type antibiotic, and tazobactam, which is a beta lactamase inhibitor.

Zosyn is used to treat bacterial infections and is effective on a wide range of bacteria due to the differing mechanisms of action of the two drugs used.

However, since it is only available in its injectable form, Zosyn’s use is limited for patients with IV access, and is reserved for moderate to serious infections such as pneumonia, gastrointestinal and genitourinary infections caused by bacteria susceptible to the drug.

It can also be used in conjunction with other antibiotics for more severe cases. Zosyn can be administered to both adult and pediatric patient populations.

Indications of Zosyn (Piperacillin-Tazobactam)

Zosyn is classified as a broad-spectrum antibiotic, which is an antibiotic that can be used to treat infections caused by a considerable number of gram-positive or gram negative bacteria.

Zosyn can be used to treat infections prior to knowing the exact causative agent, or the specific antibiotics to which the causative agent is sensitive to. It is also given if a patient has a severe infection where there is no time to wait for the results of a culture and sensitivity test or antibiogram, in an attempt to stop the spread of the causative microorganism and prevent the signs and symptoms of the infection from worsening.

Typical infections that can be treated by Zosyn include pneumonia, genitourinary infections such as urinary tract infections (UTI) and pelvic inflammatory disease (PID), and infections of the skin and gastrointestinal organs such as appendicitis.

Because it is a combination drug, Zosyn can be effective even against certain penicillin-resistant strains of gram positive and negative bacteria so long as they are susceptible to the tazobactam component of the medication.

Currently, Zosyn is available for use in the following forms:

  • IV powder single vial, to be diluted prior to injection:     2.25 g (2g piperacillin/0.25g tazobactam),  3.375 g (3g/ piperacillin/0.375g tazobactam), 4.5 g (4g piperacillin0.5g tazobactam)
  • IV powder pharmacy bulk vial: 40.5 g (36g piperacillin/4.5g tazobactam)
  • IV solution for infusion: 2.25 g (2g piperacillin/0.25g tazobactam) in 50 mL, 3.375 g (3g piperacillin/0.375g tazobactam) in 50 mL, 4.5 g (4g piperacillin/0.5g tazobactam) in 100 mL

The recommended dosage for Zosyn based on the indication is as follows:

  1. Treatment for moderate to severe infections from piperacillin-resistant, beta-lactamase producing microorganisms that are susceptible to piperacillin-tazobactam in cases of apendiscitis and periotnitis, skin and skin-strucutre infections, postpartum endometriosis, pelvic inflammatory disease and moderately severe community acquired pneumonia:
    • For adult patients and pediatric patients weighing more than 40 kg (88 lbs) : IV infusion starting at 3.375g every 6 hours for 7 to 10 days for moderate to severe infections.
    • For pediatric patients aged weighing less than or equal to 40 kg (88 lbs): If patient is 2 to 9 months old, IV infusion dose usually starts at 90 mg (80 mg/10 mg)/kg, to be infused every 6 to 8 hours. If patient is older than 9 months, IV infusion dose is at 112.5 mg (100 mg/12.5 mg)/kg to be infused every 6 to 8 hours.
  2. For patients with nosocomial or hospital-acquired infections caused by piperacillin resistant, beta-lactamse producing microorganisms susceptible to piperacillin-tazobactam: IV infusion of 4.5 gms every 6 hours to be infused over 30 minutes for 7 to 10 days. An additional antibiotic may be given concurrently as needed.

The drug administration instructions and considerations for Zosyn are as follows:

  • For powdered vials, reconstitute with 5ml of diluent for every gram of piperacillin. Dilute and infuse Zosyn using only solutions tested to be compatible with the medication to avoid unwanted chemical reactions. Shake powder with diluent until dissolved, then further dilute to achieve final volume of 50 mL prior to infusion.
  • Infuse solution over at least 30 minutes. If possible, put on hold any other infusions while infusing Zosyn. Avoid mixing Zosyn with other drugs, especially chemically incompatible medications, in the same IV container.
  • Use drug immediately after preparing. Discard any unused medication after 24 hours if stored at room temperature. If refrigerated, the reconstituted drug may be used up until 48 hours. If incorporated in IV bags, the drug can be used within 24 hours if stored in room temperature, or within one week if refrigerated.

Dosage considerations for patients with renal impairment are as follows:

  1. For all indications except for hospital acquired pneumonia:

  • For patietns with creatinine clearance of  >40 mL/min: give 3.375 g (3 g piperacillin/ 0.375 g tazobactam) IV every 6 hours.
  • For patients with creatinine clearance of 20-40 mL/min and without hemodialysis: give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 6 hours.
  • For patients with creatinine clearance of <20 mL/min and without hemodialysis: give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 8 hours.
  • For patients with hemodialysis: give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 12 hours. Give 0.75 g IV (0.67 g piperacillin /0.08 g tazobactam) as an additional dose after each hemodialysis session during dialysis days.
  • For continuous peritoneal dialysis patents: give 2.25 g IV for every 12 hours

2. For the treatment of hospital acquired pneumonia:

  • For patients with creatinine clearance of 20-40 mL: give 3.375 g (3 g piperacillin/0.375 g tazobactam) every 6 hours.
  • For patients with creatinine clearance less than 20mL and without hemodialysis:  give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 6 hours.
  • For continuous peritoneal dialysis patients:  give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 8 hours.
  • For patients with hemodialysis:  give 2.25 g (2 g piperacillin/ 0.25 g tazobactam) IV every 8 hours. Give 0.75 g IV (0.67 g piperacillin /0.08 g tazobactam) as an additional dose after each hemodialysis session during dialysis days.

Mechanism of Action of Zostn (Piperacillin-Tazobactam)

There are two active antibacterial agents in Zosyn: piperacillin and tazobactam. Both are considered bactericidal agents, meaning they treat infections by eliminating bacteria, but have different ways in doing so:

  • 1. Piperacillin
    • A penicillin type beta-lactam antibiotic, piperacillin acts by binding to a bacterium’s cell wall membrane, inhibiting further cell wall synthesis, eventually causing cell death. It is effective against both gram positive and gram negative types of bacteria, has a wider spectrum range compared to other members of the penicillin type antibiotic class. It is the more effective bactericidal agent compared to Tazobactam, but can be rendered ineffective by bacteria resistant to penicillin.
      Piperacillin can only be absorbed by the body if it is administered by IV, and even then is largely not metabolized by the liver upon absorption. Like with other penicillin type antibiotics, it is eliminated primarily by the kidneys and the liver, and traces can of the drug can be found in the urine if taken in high concentrations. Because piperacillin can also be eliminated by the liver, it can be prescribed even to patients with severe kidney problems so long as the patient is closely monitored, especially if they are also taking other medications that can only be excreted by the kidneys.
  1. Tazobactam

A beta-lactamase inhibitor, tazobactam stops the production of certain enzymes that can interfere with cell wall synthesis as well as prevent production of enzymes that make certain bacteria resistant to beta lactam antibiotics.

Tazobactam has limited use by itself as an antibiotic, and is primarily used to broaden the spectrum of antibiotics such as piperacillin. Absorption, metabolism and elimination of tazobactam depends on the antibiotic it is combined with. When administered with piperacillin, peak plasma levels are reached immediately after the ongoing IV infusion is completed, and can be maintained by infusing the initial dose every 6 hours.

Tazobactam binds to plasma proteins for about 30 percent, metabolized in the liver and is also eliminated by the kidneys, with around 80 percent of the drug in its original form remaining detectable in the urine.

Zosyn can be widely distributed in body fluids and tissues upon absorption, from the gastrointestinal organs up to nervous system tissue, although distribution in the latter is generally low unless there is presence of inflammation. It is able to cross the placenta, and is widely distributed into breast milk. Plasma half-life of Zosyn can range from 0.7 to 1.2 hours.

Side Effects of Zosyn (Piperacillin-Tazobactam)

The reported Zosyn side effects are generally mild and self-limiting, meaning they usually go away on their own once the body becomes used to taking in the medication.

  • Gastrointestinal: Abdominal pain, dyspepsia/indigestion, constipation, nausea and vomiting
  • CNS: Headache
  • Skin/Integumentary: Rash, pruritus, dry mouth, injection site reactions (e.g. redness)
  • Others: Sleeping changes (insomnia or severe sleepiness), fever
  • Laboratory values: Increased serum creatinine, BUN, ALT, AST, eosinophil count; decreased WBC, platelet count, neutrophil count, serum albumin. May cause a false-positive result for urine glucose tests if using certain testing methods.

Adverse Reactions to Zosyn (Piperacillin-Tazobactam)

Although most common side effects of Zosyn are manageable, a small percentage of patients do experience the rarer, but more severe, adverse reactions to the medication:

  • Gastrointestinal: Diarrhea, oral candidiasis, stomatitis, pseudomembranous colitis, blood sugar and electrolyte abnormalities (i.e. hypokalemia, hypoglycemia)
  • CNS: Insomia, seizures, fever, convulsions and neuromuscular excitability if given in doses higher than recommended amount
  • Integumentary/Skin: Utricaria, purpura, bullous dermatitis. In rare cases: toxic epidermal necrolysis and Stevens-Johnson syndrome
  • Genitourinary: Tubulointerstitial nephritis, nephrotoxicity, renal failure
  • Hematology: Leukopenia, neutropenia, and bone marrow suppression with prolonged therapy (equal to or more than 21 days), all of which are typically reversible; agranulocytosis, prolonged PT.
  • Hypersensitivity reaction: anaphylaxis, anaphylactic shock

Drug Interactions with Zosyn (Piperacillin-Tazobactam)

  • Zosyn and Aminoglycosides: the piperacillin component can possibly inactivate aminoglycosides, Concentrations may become significantly reduced, especially if the patient has end stage renal disease undergoing hemodialysis.
  • Zosyn and Uricosurics: Zosyn used concurrently with certain uricosurics (medications that lower uric acid levels) can increase the medication’s half-life, up to 21% for piperacillin, and up to 71% for tazobactam, since uricosurics can interfere with the kidneys’ efficiency in eliminating Zosyn. However, in some cases, use of uricosurics may be prescribed for this very purpose.
  • Zosyn and anesthetic agents: Zosyn can prolong the neuromuscular blockade effects of certain anesthetic agents due to piperacillin having smiliar mechanism of action to these anesthetics.
  • Zosyn and chemotherapeutic drugs: Taking Zosyn with certain chemotherapeutic drugs may reduce elimination of either medication from the body due to them both relying heavily on the kidneys for elimination.
  • Zosyn and other antibiotics: while there are antibiotics that can be used together with Zosyn to treat severe infections, some antibiotics, particularly those that are known to increase risk for kidney injury or renal failure, should be used with caution if they are to be used concurrently with Zosyn.
  • Zosyn and anticoagulants: since one of the known adverse reactions to Zosyn is changes in coagulation parameters (particularly PT), patients who are prescribed Zosyn while taking anticoagulants should be monitored for increased risk of bleeding.
  • Zosyn and NSAIDs: certain types of NSAIDs, particularly those that are eliminated by the kidneys, can decrease the rate which Zosyn is eliminated by the body and increase serum levels.
  • Zosyn and anticonvulsants: some anticonvulsants may increase elimination rate of piperacillin from the body, thereby lowering serum levels and decreasing antibiotic efficacy.
  • Zosyn and hormonal contraceptives: Taking Zosyn with contraceptives may decrease contraceptive effectiveness.  Additional form of contraception may be advised during therapy.

Nursing Considerations for Zosyn (Piperacillin-Tazobactam)

  1. Perform baseline assessment on the patient.
  2. Obtain the patient’s history for allergic reactions to drugs, particularly allergy to penicillins, beta-lactams, or cephalosporins, prior to drug administration. Use of Zosyn is contraindicated for patients with known hypersensitivity reaction to penicillin type antibiotics or beta-lactams, but may be used cautiously in patients allergic to cephalosporins or other drugs.
  3. Review the patient’s history for any conditions that would contraindicate them for the drug, or have signs and symptoms similar to an adverse reaction to the drug. Zosyn should be used cautiously in patients with the following conditions: congestive heart failure, bleeding disorders, uremia, renal or liver impairments, or electrolyte disorders.
  4. If Zosyn will be used in combination with certain antibiotics, perform an orientation and reflex assessment test on the patient to establish baseline data in case of a possible CNS adverse reaction.
  5. Review or ensure that the patient has the following laboratory results done to provide baseline data of tests that can be affected by administration of Zosyn: CBC, kidney and liver function tests, serum electrolytes, and clotting factors.
  6. A culture and sensitivity test should be done prior to initiating drug therapy. Once the procedure is done, the patient may proceed with the first dose of the drug.
  7. Educate the patient regarding the drug, the importance of completing the therapeutic regimen, common side effects, adverse reactions to watch out for.
  8. Ensure that the patient is able to receive the full course of the antibiotic treatment as prescribed to decrease risk of developing resistant strains of microorganisms.
  9. Monitor the patient for any signs of hypersensitivity reactions, such as fever, severe rash, flushing and difficulty of breathing. Notify the prescribing physician if a hypersensitivity reaction was noted, as the drug is known to cause episodes of anaphylactic shock in some patients. Patients with cystic fibrosis may have a higher risk of developing fever and rash, and should be monitored more closely for these reactions.
  10. Monitor the patient for any signs of bleeding such as bruising, unusual bleeding or black, tarry stools, as the drug can affect bleeding and clotting times, especially if the patient is taking anticoagulants concurrently.
  11. Monitor the patient’s urine output and ensure that the patient’s output is within normal limits, especially if the patient has a known history for kidney problems. Other signs of increased fluid retention or elimination problems may include: increased blood pressure, swelling or edema, flank pain, increased thirst and weight gain.
  12. Since the drug can affect serum electrolyte levels, most notably potassium, patients prescribed a potassium-rich and low salt diet should have their electrolytes monitored regularly. Encourage the patient to include electrolyte-rich foods in their diet while taking restrictions and electrolyte diagnostic results into consideration. Note that Zosyn contains 2.35 mEq sodium for every gram of piperacillin.
  13. Gastrointestinal symptoms are some of the common side effects of Zosyn use. If the patient is constipated, encourage adequate fluid intake and to add high fiber foods in the patient’s diet. If the patient experiences diarrhea, advise them to not take medications to treat it without first informing the prescribing physician, as doing so may worsen the symptom or make it last longer.
  14. Advise lactating mothers to avoid breastfeeding their babies without prior consultation with their physician, as the drug can be distributed in breast milk.
  15. Advise the prescribing physician if the patient is for hemodialysis or peritoneal dialysis, so that the dosage may be adjusted accordingly during dialysis periods. Peritoneal dialysis can remove up to 6% of piperacillin dose and up to 21% of tazobactam dose. Hemodialysis can remove 30 to 40% of the given dose in 4 hours.
  16. If large doses are given or if drug is given for a prolonged period of time, super infections either by bacteria or fungi may occur, especially among the elderly, immunocompromised or debilitated patients.
  17. Monitor patient’s IV infusion site for signs of phlebitis or infiltration, such as swelling, heat or coldness, and redness at the infusion site. Change IV sites every 48 hours or as needed if signs of phlebitis or infiltration are already present.

Nursing Diagnosis Zosyn (Piperacillin-Tazobactam)

Zosyn Nursing Diagnoses

  • Diarrhea related to the side effect of Zosyn
  • Pain (Musculoskeletal) related to the side effect of Zosyn
  • Risk for Bleeding  related to adverse effect of Zosyn
  • Risk for Anaphylactic Reaction related to drug allergy to Zosyn
  • Risk for Electrolyte Imbalance (Hypokalemia) secondary to adverse reaction of Zosyn

Zosyn Nursing Assessment

Zosyn Nursing InterventionsRationale
Assess the patient for signs and symptoms of bacterial infection.To confirm the indication for administering piperacillin-tazobactam (Zosyn).
Assess if the patient has hypokalemia, C.difficile infection, seizures, clotting disorders, or chronic kidney disease.Piperacillin-Tazobactam (Zosyn) are generally contraindicated in patients with hypokalemia because one of the adverse effects of this drug is to lower the serum potassium level. Patients with C.difficile infection, seizures, clotting disorders, or chronic kidney disease may receive Zosyn with caution.
Check the patient’s allergy status.Previous allergic reactions to piperacillin-tazobactam (Zosyn) may render the patient unable to take them. Alternatives to piperacillin-tazobactam (Zosyn) should therefore be considered in case of allergy.
Assess if the patient is pregnant or lactating.Piperacillin-Tazobactam (Zosyn)can be prescribed to a pregnant woman  as this drug is under pregnancy category B which means it does not impose known harm to humans. Zosyn must only be administered under the direction of the physician.
Perform a focused neurological assessment of the patient.Piperacillin-tazobactam (Zosyn) may cause adverse CNS effects.  
Assess the patient’s veins in preparation for administering Zosyn.To ensure that there is a good venous access before piperacillin-tazobactam (Zosyn) is given.
Collect blood for a kidney function check.Piperacillin-Tazobactam (Zosyn) may cause adverse effects on the kidneys if not dosed properly.

Zosyn Nursing Planning and Intervention

Zosyn Nursing InterventionsRationale
Administer piperacillin-tazobactam (Zosyn) via a peripheral or central venous line.To ensure optimal absorption and therapeutic action by piperacillin-tazobactam (Zosyn), as well as reduce possible side effects.
Monitor the venous access after administration. Ask the patient to report any pain or discomfort during and after administration of the drug.To check for any infiltration or phlebitis around the IV site.  
Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking piperacillin-tazobactam (Zosyn).To inform the patient on the basics of piperacillin-tazobactam (Zosyn).
Monitor the patient’s input and output and commence stool chart.Piperacillin-tazobactam (Zosyn) may cause diarrhea. Early detection of diarrhea can help institute a bowel program and relieve them effectively.
Discourage alcohol intake when on piperacillin-tazobactam (Zosyn).Alcohol can increase the possible GI side effects of Zosyn, such as nausea and vomiting.
Inform the patient that piperacillin-tazobactam (Zosyn) may cause nausea and vomiting and this should be reported to any healthcare professional once noticed.To inform the patient of the possible side effect of Zosyn on the gastrointestinal system, and to be able to administer antiemetics as soon as the patient reports the symptom.

Zosyn Nursing Evaluation

Zosyn Nursing InterventionsRationale
Ask the patient to repeat the information about piperacillin-tazobactam (Zosyn).To evaluate the effectiveness of health teaching on piperacillin-tazobactam (Zosyn).
Check for any signs of allergic reaction to Zosyn, such as shortness of breath, skin rash, or swelling.To ensure the patient’s safety after the initial dose of Zosyn and to be able to reverse anaphylaxis quickly.
Monitor the patient’s full blood count and kidney function.To ensure that the piperacillin-tazobactam (Zosyn) did not cause any anemia, leukopenia, or thrombocytopenia, as well as damage to the kidney function.  
Monitor the patient for any signs of bleeding such as bruising.To check for any adverse effect of Zosyn which is the risk  for bleeding.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon


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Anna Curran. RN, BSN, PHN

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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