In this episode, I’ll discuss an article about IVP antibiotic safety.
Article
Safety of intravenous push administration of beta-lactams within a healthcare system
Lead author: Kassandra Marsh, PharmD, BCIDP
Published in American Journal of Health-System Pharmacy April 2020
Background
In the aftermath of hurricane disruptions to IV solution supply chains, 2017 saw a severe minibag shortage. Many institutions chose to conserve IV minibags by converting as many antibiotics as possible to IV push administration. At the time, safety data was limited to small observational trials. The authors of this study sought to look back at that time period so as to add to the safety data available for IV push antibiotics.
Methods
The study was a 2 center retrospective review of IVP administrations of aztreonam, ceftriaxone, cefepime, and meropenem. The only exclusions were patients receiving antibiotics for surgical prophylaxis or patients receiving more than one IVP antibiotic simultaneously. The authors’ primary endpoint was the rate of adverse events following IVP administration of antibiotics.
Results
The study evaluated 1000 patients who received IVP antibiotics. Ceftriaxone and cefepime comprised over 90% of administrations while aztreonam and meropenem comprised about 4.5% each. There were only 10 adverse events observed, half of which were allergic reactions and therefore not related to IVP administration. Four adverse events were neurotoxicity related to IVP cefepime and there was 1 case of phlebitis in a patient who received IVP ceftriaxone.
Conclusion
The authors concluded:
The use of IVP as an alternative to intravenous piggyback (IVPB) during times of drug shortage for select beta-lactam antibiotics appears to be safe, and ADE are similar to those previously described for IVPB administration. Future studies evaluating clinical outcomes between IVP and IVPB administration may be of benefit.
Discussion
The instructions given to nursing staff regarding administration and monitoring were to give each antibiotic IVP over 5 minutes and to monitor for 1 hour after administration for injection site reactions, changes in mental status or heart rate, palpitations, diaphoresis, restlessness and seizure.
This study is more robust than prior literature looking at the safety of IVP antibiotics for two reasons. First, previous studies looked at phlebitis as the adverse outcome of interest; this study expanded beyond that to other possible adverse events. Second, previous studies considered only the first dose of antibiotics being given IVP; this study had patients receiving IVP antibiotics over the entire course of treatment.
The reconstitution instructions used in the study were:
- Ceftriaxone 1g per 10 mL normal saline or 2 g per 20 mL NS
- Cefepime 1g per 10 mL normal saline or 2 g per 20 mL NS
- Meropenem 0.5g per 10 mL sterile water for injection or 1 g per 20 mL SWFI
- Aztreonam 1g per 10 mL normal saline or 2 g per 20 mL NS
It would be interesting if the authors analyzed their cefepime patients for the incidence of neutropenia, as a separate study discusses the apparent increased incidence of cefepime induced neutropenia with prolonged (2+ weeks) courses of IVP cefepime.
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I have not seen any recent studies on IV push but I have also not seen reports of adverse events from IV push antibiotics either. Many hospitals that adopted IV push since the 2017 hurricanes and have continued the practice ever since. The use of Cefepime IV push administration was found to reduce the time to antibiotic administration for sepsis patients in one study and overall it provides for a quick delivery of drugs without the need for infusion lines, pumps, and pharmacy compounding.
Joe, as always good stuff. but would like to have seen you mention that push has not been proven to help clear infection as well and in fact in ICU or severely ill patients we actually may employee continuous infusion or prolonged infusion to maintain time above MIC. First dose and surgical prophylaxis, ok, push away.