In this episode, I’ll discuss the use of subcutaneous antibiotics.
The subcutaneous route of administration is often underappreciated, but it can be a solution in a number of challenging clinical scenarios. Subcutaneous dexmedetomidine can be used for sedation , and fluid replacement, aka hypodermoclysis, can also be accomplished via the subcutaneous route.
Having unique tricks like the subcutaneous route up your sleeve when you encounter patients with limited or no venous access can be useful, and a group of authors published in Clinical Infectious Diseases their bag of tricks related to When and How to Use Subcutaneous Antibiotics.
The ideal site for subcutaneous administration can be the abdominal wall, thigh, flank, deltoid, or peri-umbilical, peri-clavicular, peri-scapular regions. Look for the area among these that has intact skin, a lack of edema, and appears adequately perfused.
Subcutaneous antibiotics may be given as small volume (2 mL) bolus over a few minutes or an infusion of up to 100 mL in an hour.
For infusions, a specially designed plastic winged cannula is preferable to a metal needle to reduce the risk of local tissue injury.
Studies have mostly used normal saline as the diluent, but dextrose 5% has also been used occasionally.
The review evaluates the quality of evidence for different antibiotics being given via the subcutaneous route and categorizes them accordingly:
Antibiotics with the highest-quality evidence for safety and clinical experience are ceftriaxone and ertapenem.
Antibiotics with moderate quality evidence for safety and clinical experience are cefazolin, ceftazidime, daptomycin, and meropenem.
Antibiotics that are probably safe but have limited evidence are ampicillin, cefepime, dalbavancin, fosfomycin, metronidazole, penicillin G benzathine, and piperacillin/tazobactam.
Antibiotics that should probably be avoided due to known issues with tissue irritation are aminoglycosides, fluoroquinolones, and vancomycin.
Colistin and Polymixin B have no data yet but the authors suggest these are theoretically promising.
The authors conclude that:
SC antibiotic administration is a practical alternative to the IV route in selected patients. Available data show that several time-dependent agents, including β-lactams and teicoplanin, achieve PD targets with acceptable safety…In the context of antimicrobial stewardship and resource optimization, the SC route offers an additional tool to expand treatment possibilities while minimizing invasive procedures. Careful integration into clinical practice, supported by robust evidence, will determine its role in future infectious disease management.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
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