Intravenous antibiotic administration practices

Published Date: 19th July 2016

Publication Authors: Barton G

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INTRODUCTION

Antibiotics are the curative therapy in the management of sepsis. A point prevalence study in 2007 showed that 51 % of patients on Intensive Care Units worldwide were deemed to have sepsis with 71 % receiving antibiotics. Pharmacokinetic/pharmacodynamic (pk/pd) data suggest that some parameters such as volume of distribution and renal clearance are altered in critically ill patients potentially leading to under dosing with standard doses and methods of administration.

OBJECTIVES

To investigate antibiotic administration on Critical Care Units (CCUs) in the United Kingdom (UK) and what factors influence that practice.

METHODS

An online survey was developed to obtain details of local practices in 244 CCUs in the UK regarding the methods of administration of commonly used antibiotics, situations/conditions when practice varied from usual practice and the driving forces for deviation. The desired respondents were pharmacists regularly working on CCUs; the link to the survey was posted on the message board of the UK Clinical Pharmacy Association's Critical Care Group. University ethics approval was obtained.

RESULTS

Completed surveys were received from 64 CCUs (26.2 %). A pharmacist visits the ward weekdays only on 54 CCUs (84.3 %), everyday on 9 (14.1 %) and rarely on one. On 75 % (48/64) of CCUs the pharmacist regularly attends the consultant-led ward round. 81.3 % (52/64) of CCUs had microbiology ward rounds on weekdays, the remaining units (18.7 %, 12/64) had weekly ward rounds. Most antibiotic administration followed the licensed method, however three drugs were regularly administered via "off-label" methods such as extended intermittent infusion (EII) or continuous infusion (CI). EIIs of Piperacillin/Tazobactam and Meropenem were used as usual practice on 14 (21.8 %) and 13 (20.3 %) of responding units respectively. One Trust with four CCUs used EIIs of Benzylpenicillin,

Flucloxacillin, Cefuroxime, Ceftazidime and Co-amoxiclav. Vancomycin is the only antibiotic usually given by CI, this occurred on 33/64 units (51.5 %). The most commonly stated reason for using EII/CIs was "evidence based - pk/pd studies" selected by 29/64 respondents (45.3 %). For patients receiving renal replacement therapy (RRT) two CCUs changed administration practice from bolus to EII. Piperacillin/Tazobactam and Meropenem were given as EIIs when treating patients with major burns on two CCUs and one CCU used them for the treatment of pseudomonas. 100 % of respondents used the same total daily dose regardless of method of administration and did regular therapeutic drug monitoring for vancomycin and gentamicin but none was undertaken for any other classes of antibiotics (e.g. penicillins).

CONCLUSIONS

Although most usual administration practice matched the product license there is a trend towards EIIs for Piperacillin/Tazobactam and Meropenem and over half of responding units use Vancomycin by CI. Further study is warranted to justify these off label practices.

Barton, G; Henney, N; Morecroft, C. (2014).  A survey of intravenous antibiotic administration practices in UK critical care units . Intensive Care Medicine. 40 (Supplement 1), S261.

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