Intravenous Push Administration of Antibiotics: Literature and Considerations

Intravenous push antibiotics in the emergency department: Education and implementation

PURPOSE

Intravenous push antibiotics can serve as an alternative to intravenous piggyback antibiotics while providing the same pharmacodynamics and adverse effect profile, easing shortage pressures and decreasing order to administration time, as well as representing a potential cost savings. The purpose of this study was to determine whether intravenous push antibiotics could decrease the time from an order to the start of administration compared to piggyback antibiotics in emergency departments. This study also measured the cost savings of antibiotic preparation and administration and assessed nursing satisfaction when using intravenous push antibiotics.

METHODS

Sample instances of use of intravenous push and piggyback antibiotics were identified. Patients were included if they were 18 years of age or older and received at least a single dose of intravenous push or piggyback ceftriaxone, cefepime, cefazolin, or meropenem in one of the institution's emergency departments. The primary outcome of the study was to compare the time from the order to the start of administration of intravenous push vs piggyback antibiotics. The secondary outcome was to compare the cost of antibiotic preparation for the 2 methods.

RESULTS

The intravenous push and piggyback groups each had 43 patients. The time from the order to the start of administration decreased from 74 (interquartile range, 29-114) minutes in the piggyback group to 31 (interquartile range, 21-52) minutes in the push group (P = 0.003). When the estimated monthly cost savings for ceftriaxone, cefepime, and meropenem were added together, across the emergency departments, an estimated $227,930.88 is saved per year when using intravenous push antibiotics.

CONCLUSION

Intravenous push antibiotics decrease the time from ordering to the start of administration and result in significant cost savings.

Successful implementation of safe practice for adult intravenous push medication in a tertiary care hospital: determination of stability of four intravenous antibiotics in syringes

In 2017, a severe shortage of infusion bags resulted in a paradigm change in medication administration practice from intermittent infusion to intravenous push. The Institute for Safe Medication Practices proposed safe practice guidelines for adult intravenous push medications. A different study showed that ready-to-administer medication prepared in the sterile area of a pharmacy reduces the risk of harm, nurses' time for medication administration and the cost of medications. Based on the recommendation of the Institute for Safe Medication Practices, we decided to conduct a pilot study on the implementation of sterile compounding and administration of intravenous push medication in adult patients admitted to the hospital. In the study, the stability of five intravenous push antibiotic syringes was also determined in the syringes.

An Emergency Department Quality Improvement Project for Intravenous Levetiracetam Administration

Background: Levetiracetam is a readily available, safe anticonvulsive medication. It is frequently administered as IV piggyback with a pump, carrier fluid, and tubing. The Established Status Epilepticus Treatment Trial demonstrated levetiracetam being similarly effective to previously used treatments in doses up to 4500 mg administered over 10 minutes. Objective: We sought to compare usage, cost, and waste of IV piggyback with IV push administration of levetiractam following implementation of an IV push protocol in an academic emergency department. Methods: A three-month review of levetiracetam administration was done following protocol implementation using IV push for initial treatment of benzodiazepine-refractory status epilepticus. The review quantified the number of IV push vs IV piggyback doses for all indications and evaluated cost of supplies necessary for administration. Results: During the study period, 137 patients received 142 doses of IV levetiracetam. Fifty-one doses (36%) were given as IV push rather than IV piggyback. The majority of doses 116 (82%) were 1000-2000 mg and 11 doses (8%) 3500-4500 mg. Estimated three-month savings with complete transition of IV piggyback to IV push would exceed $6000 just in our ED. The amount of sterile solution carrier fluid was also reduced and IV pump time freed. Conclusion: Implementation of an emergency department IV push levetiracetam protocol resulted in cost savings. Opportunities remain to improve clinical implementation practices. Medication administration represents one crucial target area where healthcare systems can implement policies to reduce waste and commit to climate-smart health care.

Integrating Evidence-Based Practice Into an Emergency Department Nurse Residency Program

Evidence-based practice (EBP) is a problem-solving approach that combines the best evidence and research with clinical knowledge in order to improve patient outcomes. Providing nurses with the tools for utilizing EBP is essential, especially for graduate nurses hired in an emergency department. This article describes how EBP is integrated into the curriculum of a nurse residency program. It discusses methodology of education and describes the development of an evidence-based project.

Outcomes of Intravenous Push versus Intermittent Infusion Administration of Cefepime in Critically Ill Patients

The equivalence of intravenous push (IVP) and piggyback (IVPB) administration has not been evaluated in the critically ill population for most medications, but it is especially relevant for antibiotics, such as cefepime, that exhibit time-dependent bactericidal activity. A single center, retrospective, observational pre/post-protocol change study included critically ill adults who received cefepime as empiric therapy between August 2015 and 2021. The primary outcome was treatment failure, which was defined as a composite of escalation of antibiotic regimen or all-cause mortality. Secondary outcomes included adverse drug events, days of cefepime therapy, total days of antibiotic therapy, and ICU and hospital length of stay. Outcomes were compared using Chi-squared, Mann Whitney U, and binary logistic regression as appropriate. A total of 285 patients were included: 87 IVPB and 198 IVP. Treatment failure occurred in 18% (n = 16) of the IVPB group and 27% (n = 54) of the IVP group (p = 0.109). There were no significant differences in secondary outcomes. Longer duration of antibiotics (odds ratio [OR] 1.057, 95% confidence interval [CI] 1.013-1.103), SOFA score (OR 1.269, 95% CI 1.154-1.397) and IVP administration of cefepime (OR 2.370, 95% CI 1.143-4.914) were independently associated with treatment failure. Critically ill patients who received IVP cefepime were more likely to experience treatment failure in an adjusted analysis. The current practice of IVP cefepime should be reevaluated, as it may not provide similar clinical outcomes in the critically ill population.

Pushing the agenda for intravenous push administration in outpatient parenteral antimicrobial therapy

Intravenous push (IVP) antimicrobial administration refers to rapid bolus infusion of medication. This drug delivery method offers improved patient convenience, superior patient and nursing satisfaction, and cost savings when used in outpatient parenteral antimicrobial therapy (OPAT). Antimicrobial agents must demonstrate optimal physiochemical and pharmacologic characteristics, as well as sufficient syringe stability, to be administered in this manner. Additionally, impacts on medication tolerability, patient safety, and effectiveness must be considered. This narrative review summarizes the available data and practical implications of IVP administration of antimicrobials in the OPAT setting.

Staphylococcal scalded skin syndrome: Clinical features, ancillary testing, and patient management

BACKGROUND/OBJECTIVES

The utility of ancillary testing in improving diagnostic precision or improving patient outcomes in staphylococcal scalded skin syndrome (SSSS) is unclear. Similarly, an optimal antibiotic regimen has yet to be established. Our goal was to describe clinical characteristics and ancillary work-up of SSSS, report bacterial resistance patterns, and examine patient outcomes under varying therapeutic strategies with the aim of developing an evidence-based management algorithm.

METHODS

We performed a retrospective review of pediatric patients diagnosed with SSSS at Intermountain Healthcare facilities between 2010 and 2021. A Kruskal-Wallis rank sum test was used to assess median length of stay between different antibiotic regimens.

RESULTS

Eighty-five cases were identified. The most common ancillary tests obtained were a complete blood count (88%), followed by chemistry analysis (80%). Blood cultures were collected in more patients (79%) compared to aerobic cultures (60%). No blood culture was positive for Staphylococcus aureus. All S. aureus isolates were methicillin-sensitive. Of those found resistant to clindamycin (36%), all demonstrated macrolide-induced clindamycin resistance. None were constitutively resistant to clindamycin. There was no statistical difference between antibiotic regimen and length of stay (p = .691). Receiving opiate medications was the only risk factor associated with prolonged hospitalization (p = .001).

CONCLUSIONS

Ancillary testing does not improve diagnostic precision and can be reduced. Clindamycin does not improve patient outcomes, suggesting beta-lactams should be considered first line. Susceptibility patterns in our cohort demonstrate inducible clindamycin resistance as opposed to constitutive.

Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria

Background

Prior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health.

Methods

Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration.

Results

One-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar.

Conclusion

The abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.

Clinical Considerations for Rapid Administration of Undiluted or Minimally Diluted Levetiracetam Bolus Doses

INTRODUCTION

The ability to administer medications via rapid intravenous bolus has the potential to allow for the rapid attainment of therapeutic drug levels and to limit the amount of unnecessary fluid volumes infused. The purpose of this review was to evaluate the efficacy and safety of undiluted or minimally diluted levetiracetam bolus doses.

AREAS COVERED

A total of six pieces of literature were evaluated in this review. Doses up to 4,500 mg of intravenous levetiracetam were found to be both efficacious and safe when administered undiluted or minimally diluted in either a peripheral or central line. Product concentrations of levetiracetam ranged from 50 mg/mL to 100 mg/mL, with volumes ranging from 10-30 mL's. Maintenance doses of up to 1,500 mg twice daily were demonstrated to be both efficacious and safe when administered undiluted or minimally diluted. Injection site pain and agitation were the most commonly reported adverse drug effects.

EXPERT OPINION

Though hospitals and clinicians must be judicious with regard to training and the safety concerns of bolus intravenous push doses, and will need to address numerous logistical concerns, this practice is supported in practice guidelines and should be readily employed.

Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice

The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.

Safety of Intravenous Push Ertapenem Compared to Intravenous Piggyback at a Tertiary Academic Medical Center

Background: Recent shortages of intravenous (IV) fluids have resulted in healthcare systems converting administration of many medications from IV piggyback (IVPB) to IV push (IVP). Administering medications via IVP presents numerous advantages; however, IV site reactions such as phlebitis and infiltration may occur. Objective: The objective of this analysis is to evaluate the infusion site safety of ertapenem given as peripheral IVP compared to IVPB in adult patients. Methods: This was an institutional review board-approved, single-center, retrospective study. Patients, ages 18 or older, receiving IV ertapenem were identified. The major endpoints analyzed were IV site reactions including phlebitis and infiltration. The Naranjo Nomogram was utilized to assess the causality of the reactions to determine the likelihood of whether the event was caused by the medication itself or other factors. Results: To date, 283 administrations (92 patients) in the IVP group and 319 administrations (82 patients) in the IVPB group were analyzed. There were 13 IV site reactions compared to 8 in the IVP vs IVPB group, respectively (P-value = 0.16). Ten of the events in the IVP group were deemed "possible" and 2 deemed "doubtful," while the remaining event was considered "probable" per the Naranjo Nomogram. Of the events in the IVPB group, all 8 were found to be "possible." Conclusion: The administration of IVP ertapenem showed comparable rates of infusion site reactions compared to IVPB. Implementation of IVP ertapenem appears to be associated with infusion site safety similar to IVPB and should be considered safe to administer.

Pharmacokinetic and Pharmacodynamic Target Attainment in Adult and Pediatric Patients Following Administration of Ceftaroline Fosamil as a 5-Minute Infusion

The key pharmacokinetic/pharmacodynamic (PK/PD) efficacy index for β-lactam antibiotics is the percentage of time that free drug concentrations exceed the minimum inhibitory concentration (MIC) of bacteria during each dosing interval (fT>MIC). Ceftaroline fosamil, the prodrug of the β-lactam ceftaroline, was initially approved for administration as 60-minute intravenous (IV) infusions. Population PK analyses comparing exposure and PK/PD target attainment for 5-minute and 60-minute IV infusions, described here, have supported ceftaroline fosamil labeling updates to include variable infusion durations of 5 to 60 minutes in adults and children aged ≥2 months. A 2-compartment disposition PK model for ceftaroline fosamil and ceftaroline was used to predict steady-state ceftaroline exposures (maximum plasma concentrations [Cmax,ss ] and area under the plasma concentration-time curve over 24 hours [AUCss,0-24 ]) and probability of target attainment in simulated adult and pediatric patients with various degrees of renal function receiving standard doses of ceftaroline fosamil as 5-minute or 60-minute IV infusions. Across age groups and renal function categories, median ceftaroline AUCss,0-24 values were similar for 5-minute and 60-minute infusions, whereas Cmax,ss was up to 42% higher for 5-minute infusions. Both infusion durations achieved >99% probability of target attainment based on PK/PD targets for Staphylococcus aureus (35% fT>MIC) and Streptococcus pneumoniae (44% fT>MIC) at European Committee on Antimicrobial Susceptibility Testing/Clinical and Laboratory Standards Institute MIC breakpoints (1 mg/L and 0.25/0.5 mg/L, respectively). These findings support administration of standard ceftaroline fosamil doses over 5 to 60 minutes for adults and children aged ≥2 months, providing added flexibility to clinicians and patients.

Evaluation of First-Dose, Intravenous Push Penicillins and Carbapenems in the Emergency Department

BACKGROUND

Early appropriate antibiotic administration is associated with improved outcomes in infectious illnesses. During drug shortages in 2017, the American Society of Health-System Pharmacists recommended intravenous push (IVP) administration of medications when possible to conserve small-volume parenteral solutions. Data supporting IVP penicillins and carbapenems was limited.

OBJECTIVE

The primary objective of this study compared time from patient emergency department (ED) arrival to antibiotic administration between IVP and intravenous piggy-back (IVPB) administration.

METHODS

This single-center pre-post protocol study assessed changes in administration timing and safety of ampicillin/sulbactam, piperacillin/tazobactam, and ertapenem from 2015-2018. Medication administration by IVPB (pre) or IVP (post), ED arrival, antibiotic order and administration times, potential effectors of administration time, and safety events were assessed. Acquisition costs were estimated.

RESULTS

A total of 696 administrations were included, with 351 and 345 subjects in the IVPB and IVP cohorts, respectively. The median time from ED arrival to initiation of antibiotic administration was 140 (IQR 87-221) minutes and 110 (IQR 68-181) minutes in the IVPB and IVP cohorts, respectively, (P < 0.01). IVP administration increased the proportion of indexed antibiotics administered within 60 minutes of ED arrival compared to IVPB (20% vs. 12%, respectively, P < 0.01). There was no difference in adverse events between both cohorts. Supply acquisition cost savings totaled an more than $5,000 with the IVP protocol.

CONCLUSION

IVP administration of ampicillin/sulbactam, piperacillin/tazobactam, and ertapenem improved times to initiation of empiric, first-dose antibiotics in the ED without an increase in adverse events, saving over $5,000 annually.

Collaborative Antimicrobial Stewardship in the Emergency Department

Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.

Third Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems-2018

PURPOSE

The Third Consensus Conference on the Safety of Intravenous Drug Delivery Systems was convened to evaluate the benefits and risks of available systems and assess ongoing threats to the safety of intravenous drug delivery.

SUMMARY

The Third Consensus Conference on the Safety of Intravenous Drug Delivery Systems convened in Chicago, Illinois in November 2018. An expert panel of healthcare providers with experience in medication quality and safety, pharmacy and nursing operations, information technology, and/or sterile compounding led the conference. An experienced audience of approximately 30 healthcare leaders provided feedback to the panel via preconference survey and during the conference. Additionally, expert speakers presented on a range of issues, including the effects of drug shortages, the impact of standards and guidelines, and patient and administrator perspectives on the importance of intravenous drug delivery safety.

CONCLUSION

At the end of the conference, the expert panel concluded that manufacturer ready-to-use products remain the safest intravenous drug delivery system due to their many benefits and low overall risk profile. The panel identified various ongoing threats to the safety of intravenous drug delivery, with major concerns including the impact of drug shortages and lack of intravenous product standardization. Finally, the panel agreed upon a series of statements designed to advance the safety of intravenous drug delivery in healthcare institutions.

Saline in Dermatology: A literature review

BACKGROUND

Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience.

METHODS

We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks.

RESULTS

Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

CONCLUSIONS

The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

β-lactam dosing strategies: Think before you push

OBJECTIVES

There has been interest in administering cefepime, a β-lactam antibiotic, via intravenous push (IVP) as a means to improve time to first-dose antibiotic and reduce cost; however, the downstream impacts on antibiotic exposure and pharmacodynamic efficacy need to be further evaluated.

METHODS

This study used a population pharmacokinetic model for cefepime and simulated exposures to predict the pharmacodynamic (PD) effect for cefepime regimens administered via IVP or 30-minute intermittent infusion in adults with different renal functions. FDA-approved adult dosages of 1-2 g every 8 or 12 hours were compared. This study aimed to compare the absolute difference in pharmacodynamic probability of target attainment (PTA) between IVP and intermittent infusion, defined as free cefepime concentrations above organism MIC for ≥ 70% of the time.

RESULTS

At MICs of 0.25-0.5 mg/L, absolute differences in PTA were observed, with a reduction as great as 2.3% (89% to 86.7% for 30-minute intermittent infusion and IVP, respectively). At MICs of 1-4 mg/L, 30-minute intermittent infusion and IVP exhibited PTA differences as great as 5.4%, from 89.4% to 84%, respectively. At MICs of ≥8 mg/L, similar absolute differences existed; however, no regimen achieved a PTA >70%. Across renal function strata of 60, 100 and 140 mL/minute (within the same dosing group and MICs), better renal function lowered PTAs.

CONCLUSIONS

Simulations demonstrated that IVP cefepime resulted in lower PTAs than traditional intermittent infusion among a subset of elevated MICs. Clinicians should exercise caution in IVP strategy, as unintended clinical consequences are possible.

Safety and tolerability of i.v. push piperacillin/tazobactam within an emergency department

PURPOSE

Piperacillin/tazobactam is a broad-spectrum antibiotic that is widely used and commonly administered via the intravenous (i.v.) piggyback route over 0.5 to 4.0 hours. Recommendations for i.v. push (IVP) administration of piperacillin/tazobactam are lacking due to the high osmolality of the solution. The primary objective of this study was to retrospectively assess the safety and tolerability of piperacillin/tazobactam administered peripherally by IVP. Methods. A retrospective chart review was conducted to evaluate adverse drug reactions after administration of a single dose of IVP piperacillin/tazobactam through a peripheral line in an emergency department from August 2016 through November 2017.

RESULTS

A total of 1,813 patients received 1 dose of IVP piperacillin/tazobactam during the study timeframe. Three hundred patients were randomly selected for assessment of safety and tolerability. Two hundred ninety-nine patients (99.7%) tolerated IVP piperacillin/tazobactam. One patient had an allergic reaction that included itching and hives. No infusion-related reactions were documented.

CONCLUSION

IVP administration of piperacillin/tazobactam through a peripheral site is safe and tolerable for adult patients.

The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference

This review was prepared in advance of the Third Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems that was held at the W Hotel in Chicago, Illinois, from November 1 through 3, 2018. The purpose of this conference was to evaluate the safety of intravenous (IV) infusion systems used for medication administration. The expert panel of pharmacists, physicians, and nurses updated the findings of the Second Consensus Development Conference in 2009 that reviewed 5 IV drug delivery systems (manufacturer ready to use, outsourced ready to use, point-of-care activated, pharmacy compounded, and nonpharmacy compounded at point of care) with regard to applicability, ease of use, regulatory compliance, cost, safety, and implementation. The Third Consensus Development Conference expanded on previous findings by reviewing proceedings related to new standards, legislation, technologies, and shortage-related challenges related to IV medication administration that have been published since 2009. Invited faculty and audience members participated in revising a preliminary report summarizing these changes during the meeting.