ASHP Midyear: Bolus Dose of Antibiotic May Improve in Septic Shock

Mario Riccardi, PharmD, PGY1 resident, Shore Medical Center, discusses a practice improvement project aimed at administering first-dose antibiotics to septic shock patients via intravenous (IV) push rather than the traditional 30 to 60-minute continuous infusion. This approach is supported by sepsis guidelines, which recommend administering IV antibiotics within 1 hour of shock recognition, as delays can increase mortality. The IV push method offers logistical benefits, such as reduced space and labor costs in the emergency department pharmacy, as the smaller vial sizes can be stored more easily and require less preparation time. However, Riccardi notes that not all antibiotics are suitable for bolus dosing, and repeated IV push administration can lead to subtherapeutic levels.

Pharmacy Times: What is the difference between intravenous infusion for antibiotics and intravenous push antibiotics?

Mario Riccardi: Traditionally, antibiotics are usually given over like a 30 to 60-minute continuous infusion, and there's some variability between that, depending on what the dose might be or the drug itself, whereas an [intravenous (IV)] push antibiotic is usually given or can be given over a few minutes in a bolus dose.

Pharmacy Times: What are the benefits of intravenous push antibiotics for patients with septic shock?

Mario Riccardi: So there's many potential benefits for patients with septic shock surviving sepsis guidelines recommend administration of IV push antibiotics within 1 hour of recognition of the shock. That's because there's data to support after the 1 hour there's an increase in mortality. Additionally, there's logistical benefits, because the IV infusions take up space in the emergency room pharmacy, we're able to store more down there because there's only tiny vials. In addition, it takes away from labor costs of pharmacy having to prepare and then verify the dose and dispense it down to the [emergency department.]

Pharmacy Times: Are there any limitations to this therapy?

Mario Riccardi: Some of the limitations of that ,not all antibiotics would be able to be given as a bolus dose. Additionally, repeated bolus dosing has shown in some studies to have sub-therapeutic levels. So really, it's only indicated for patients the first dose given in the emergency department, everything after that should be scheduled.

Pharmacy Times: Can you describe the study of the intravenous push administration?

Mario Riccardi: This is more of a practice improvement project, rather than just the study. So what we're going to do is that whenever there's an emergency room pharmacist on staff, at least at first all one-time, doses of antibiotics given in the emergency room will be converted to IV bolus doses. Nurses will be able to just pull these vials or from the omnicell, bring it to the bedside and prepare for sterile water.

Pharmacy Times: What are the primary and secondary end points of this study, and why were these chosen to be evaluated?

Mario Riccardi: The primary endpoint is the time from pharmacist verification to the drug actually being administered to the patient. This was chosen to ensure that no one falls out of that 1 hour window, and that we're making a difference in the average time. The secondary endpoints include the rate of water verification to the patient being discharged or admitted to the hospital. There will be a total cost benefit analysis at the end. We're also going to assess the rate of adverse events, as well as nursing satisfaction with the process.