Changing antibiotics from IV infusion to IV injection mitigates the effects of a critical supply shortage

From the 2018 HVPAA National Conference

Timothy Brown (University of Texas Southwestern Medical Center, Dallas, TX;), Neil Keshvani (University of Texas Southwestern Medical Center, Dallas, TX;), Arjun Gupta (University of Texas Southwestern Medical Center, Dallas, TX;), Norman Mang (Parkland Health and Hospital System), Wenjing Wei (Parkland Health and Hospital System), Jessica Ortwine (Parkland Health and Hospital System), Kavita Bhavan (University of Texas Southwestern Medical Center, Dallas, TX;), David Johnson (University of Texas Southwestern Medical Center, Dallas, TX;), Deepak Agrawal (University of Texas Southwestern Medical Center, Dallas, TX;)

Background

In inpatients, numerous medications are administered via intravenous (IV) infusion in small-volume normal saline bags. The 2017 hurricanes in Puerto Rico introduced a critical supply disruption of small-volume normal saline bags, resulting in a price increase on the “grey market”. Our institution evaluated possibilities for decreasing reliance on small-volume infusions.

Objectives

Describe our institutional experience in changing select antibiotics from standard intravenous infusions to IV injections (“push”).

Methods

We reviewed pharmacy data to identify medications that are frequently administered via small-volume intravenous infusions. Subsequently we determined which medications could be safely changed to IV pushes, focusing on antibiotics in the inpatient setting. Baseline data was collected and the effect change was analyzed.

Results

Antibiotics made up the majority of small volume IV infusions in the inpatient setting. In response to the shortage, the order for ceftriaxone was first changed exclusively to IV push, owing to known safety with this route of administration. This change successfully prevented reliance on a rapidly decreasing supply of small-volume IV solutions. No adverse events were reported through the institutional safety reporting mechanism with regards to ceftriaxone administration. Following this experience, further changes were made to the antibiotic formulary at our institution. Highly bioavailable antibiotics, including azithromycin, doxycycline 100mg tablets price, trimethoprim-sulfamethoxazole (except for PCP pneumonia), and voriconazole were transititoned to an oral route by default unless review with a collaborating pharmacist confirmed the need for IV administration. Furthermore, aztreonam, cefazolin, cefepime, ertapenem, meropenem, and daptomycin were changed from IV infusion to IV push given similar predictable and safe pharmacokinetics for IV push and stability in smaller volumes of saline. These changes allowed for conservation of small volume IV infusion bags for medications such as vancomycin, micafungin, liposomal amphotericin, ganciclovir, and zidovudine that cannot be administered by IV push due to less predictable pharmacokinetics or known high-risk adverse events from rapid infusions.

Conclusion

Many IV antibiotics are administered by IV infusion as a default for administration for several reasons, including nursing convenience, stability of the medications in smaller volume administrations, and local established practices. In response to a critical supply disruption, our institution swiftly enacted practice changes that effectively increased the value of care without introducing any adverse events.

Implications for the Patient

Antibiotics traditionally administered via IV infusions can be safely changed to IV pushes or oral administration in order to conserve small-volume normal saline without any apparent adverse events.

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