CUH AB Guidelines Appendix 7 IV Preparations

Appendix 7: Intravenous Antibiotic Administration - Adults


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Reconstitution

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Aciclovir 
250mg and 500mg vials

Mayne Pharma brand does not need reconstitution.

Zovirax® brand: Add 10ml of sterile water for injection (WFI) or normal saline (NS) to reconstitute each 250mg vial to give 25mg/ml solution.
Shake well to ensure complete dissolution.
Use reconstituted vial immediately.

Sodium chloride 0.9% (Normal saline - NS)

Intermittent IV infusion over at least 1 hour.
Doses of 250 and 500mg should be diluted with 100ml of NS.
Doses of 500-1000mg should be diluted with 250ml of NS.
Infusion concentrations should not exceed 5mg/ml

Reconstituted solution should not be refrigerated as precipitate will form.
Maintain adequate hydration of the patient.
To avoid excessive dosage in obese patients, doses should be calculated using ideal body weight for height.

Amikacin
100mg and 500mg vials

Already in solution

NS & Glucose 5% (G5)

IV injection-give slowly over 2-3 minutes. (Bolus not recommended for once daily dosing).

IV infusion-dilute to 2.5mg/ml with compatible infusion fluid and infuse over 30 minutes. Diluted solutions should be used immediately.

Monitor plasma concentrations and renal function.
Ensure patient is well hydrated.

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Amoxicillin
500mg vial
(Amoxil®)

Add 10ml of WFI to 500mg vial.
Reconstituted vials should be used immediately.

NS (preferred infusion fluid), G5 &
Hartmann’s

IV injection-give slowly over 3-4 minutes
Intermittent IV Infusion-dilute to desired volume (e.g. 50-100ml) with compatible infusion fluid and give over 30-60 minutes.

Rapid IV administration may result in seizures.
A transient pink colour or opalescence may appear on reconstitution.

Amphotericin Liposomal
(AmBisome ®)
50mg vials

Add 12ml of WFI provided to each 50mg vial to give a 4mg per ml solution.
Shake vigorously for at least 30 seconds immediately after the addition of water and ensure complete dispersion. Reconstituted solution is stable for 24 hours if refrigerated.
Calculate the amount of liposomal Amphotericin required for further dilution.
Withdraw the calculated volume of reconstituted solution into a sterile syringe. Using the 5-micron filter provided, add the required dose to infusion fluid.

G5 only

Recommended final  concentration of 0.20-2mg/ml.
IV line must be flushed with Glucose 5% before and after infusion. If this is not possible Amphotericin should be administered through a separate line.

IV infusion only. Administer dose over 30-60 minutes and over 2 hours for doses greater than 5mg/kg/day

Prior to the administration of the first dose, a test dose of 1mg should be administered slowly for up to for up to 10 minutes and the patient carefully observed for 30 minutes after.
If tolerated, the rest of the prescribed dose can be administered.

Incompatible with saline, saline solutions or other drugs so avoid solution with Amphotericin as they may result in precipitation.
Do not use reconstituted solution if there is any sign of precipitation.

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Anidulafungin
100mg vial
(Ecalta®)

Reconstitute each vial with 30ml WFI and allow to stand for up to five minutes

NS & G5

IV infusion- add 100mg (30ml) to 100ml infusion fluid and 200mg (60ml) to 200ml to give a concentration of 0.77mg/ml.  Administer at a maximum rate of 1.4ml/min (i.e. 100mg over at least 90 minutes and 200mg over at least 180 minutes).

Discard the solution if any particular matter or discolouration are present. 

Benzylpenicillin 600mg vials
(Crystapen®)

1 mega unit = 600mg

Add 4-10ml WFI or NS to each vial and use immediately

NS & G5

IV injection-give slowly at a rate not greater than 300mg/minute
Intermittent IV infusion-dilute each 600mg vial with 10ml WFI or NS then further dilute with 100ml infusion fluid. and administer over 30-60 minutes

For high doses, give slowly to avoid electrolyte imbalance (2.8mmol of sodium per 1g Benzylpenicillin sodium salt).

Caspofungin
50 & 70mg vials
(Cancidas®)

Allow vial to reach room temperature. Add 10.5ml WFI and mix gently to dissolve.
Then withdraw 10ml to provide the full 50mg or 70mg dose.  For a dose of 35mg, withdraw 5ml from the 70mg vial, or 7ml from the 50mg vial.

NS & Hartmann’s

IV infusion only-dilute the required dose in 250ml of compatible infusion fluid and give over 60 minutes.
Doses of 50mg or less may be diluted in 100ml if required in fluid restricted patients.

Incompatible with glucose solutions
Do not use hazy, precipitated or discoloured solutions.

Cefotaxime
500mg, 1g, 2g vials
(Claforan®)

Add 2ml WFI to 500mg vial.
Add 4ml WFI to 1g vial.
Add 10ml WFI to 2g vial.
Shake well to dissolve and use immediately.

NS or G5

IV injection-give slowly over 3-5 minutes
IV infusion-1-2g diluted in 100ml of compatible infusion fluid and administered over 30-60 minutes

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Ceftazidime
500mg, 1g and 2g vials
(Fortum®)

Add 5ml WFI to 500mg vial.
Add 10ml WFI to 1g and 2g vials.

NS & G5

IV injection-give slowly over 3-5 minutes.
IV infusion- After reconstitution, dissolve contents then insert a second needle to relieve internal pressure in the vial. Dilute further in a compatible infusion fluid of 50-100ml. Mix well and give over 30 minutes.

Ceftriaxone
1g and 2g vials
(Rocephin®)

Add 10ml WFI to each vial.

NS & G5

IV injection-give 1g slowly over 2-4 minutes.
IV infusion- Add 2g to 50ml of infusion fluid and give over at least 30 minutes.

Ceftriaxone must not be mixed or administered simultaneously with calcium containing solutions (e.g. Hartmann’s) or products, even via different infusion lines. Calcium-containing solutions or products must not be administered within 48 hours of the last administration of Ceftriaxone.
Do not give with total parenteral nutrition.

Cefuroxime
750mg, 1.5g vials
(Zinacef®)

Add 7ml WFI to 750mg and 15ml WFI to 1.5g vials

NS, G5 & Hartmann’s

IV injection-give slowly over 3-5 minutes.
IV infusion- dilute reconstituted solution in 50-100ml of compatible infusion fluid and administer over 30 minutes.
 

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Chloramphenicol
1g vial
(Kemicetine Succinate®)

Add 9.2ml of WFI or sodium chloride 0.9% to each vial to give 100mg per ml solution (NB: reconstitution of other brands may differ; check package insert or contact pharmacy for more information)

NS & G5

IV injection (preferred) – give reconstituted solution directly into vein over at least 1 minute.
IV infusion – administer over 30 minutes in suitable volume of compatible infusion fluid (concentration not exceeding 20mg/ml).

Unlicensed medicine in Ireland.
IV injection preferred to infusion in order to attain high levels.
Do not use cloudy solutions.

Ciprofloxacin
200mg in 100ml
400mg in 200ml
(Ciproxin® & Hospira)

Already in solution

N/A

IV infusion-Administer 200mg over 30-60 minutes and 400mg over 60 minutes

Keep in original container to protect from light until required for use.
Each 100ml of solution contains 15.4mmol of sodium. Patient should be well hydrated to prevent crystalluria.

Clarithromycin
500mg vial
(Klacid®)

Add 10ml WFI

NS & G5

IV infusion-Add reconstituted solution to 250ml of compatible infusion fluid and administer over 60 minutes into large proximal vein.

Not to be administered as a bolus.
Monitor injection site for inflammation or phlebitis.
Do not administer to patients receiving cisapride, pimozide, terfenadine or ergotamine. 

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Clindamycin
300mg in 2ml amp or 600mg in 4ml amp
(Dalacin C®)

Already in solution, must be further diluted before administration

NS & G5

IV infusion- doses up to 900mg may be given in 50-100ml and doses of 900mg or more in 100ml of infusion fluid .  Give over 10-60 minute at rate not exceeding 30mg/min. 

Concentration should not exceed 18mg/ml.

Not more than 1200mg of clindamycin should be given in a one hour period.

Co-amoxiclav
600mg &1.2g vials
(Augmentin®)
Amoxicillin/clavulanic acid

Add 10ml WFI to 600mg vials and 20ml WFI to 1.2g vials

NS & Hartmann’s

IV injection-give slowly over 3-4 minutes.
IV infusion-dilute 600mg in 50ml and 1.2g in 100ml of compatible infusion fluid and administer over 30-40 minutes.

Vials must be used within 20 minutes of reconstitution.

Colomycin
0.5 and 1 million unit vials

Add 10ml of NS or WFI

NS or WFI

Intermittent IV infusion – dilute to 50ml with compatible fluid and infuse over 30 minutes

Co-trimoxazole 480mg/5ml amps
(Septrin®)
Sulphamethoxazole
/trimethoprim

Already in solution

G5 (preferable)

NS (not for the more concentrated dilution)

Intermittent IV Infusion- dilute in compatible infusion fluid as follows:
5ml (480mg) in 125ml,
10ml (960mg) in 250ml,
15ml (1440mg) in 500ml,
20ml (1920mg) in 500-1000ml,
25ml (2400mg) in 500-1000ml.
Shake well to ensure thorough mixing.  Dilute immediately before use and administer over 60 to 90 minutes.

For fluid restricted patients: each 5ml amp may be diluted with 75ml with G5 and administered over a maximum of 60 minutes. Other diluents should not be used.

Monitor the infusion carefully and discard if it becomes cloudy or if crystals form.

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Daptomycin
350 & 500mg vials
(Cubicin®)

Add 7ml NS to 350mg vial and 10ml NS to 500mg vial. Gently rotate vial without shaking. Allow to stand for at least 10 minutes then rotate gently to dissolve.

NS

Intermittent IV infusion-dilute required dose in 50ml of NS and administer over 30 minutes.

IV injection: give slowly over 2 minutes

Can interfere with assay for prothrombin time and INR - take blood sample immediately before dose.
Monitor creatinine phosphokinase before and regularly during treatment (at least once weekly).

Erythromycin
1g vials
(Erythrocin®)

Add 20ml of WFI to each 1g vial

NS

Intermittent IV infusion- dilute with 250ml of NS and infuse over at least 1 hour. Concentration should not exceed 5mg/ml.

Causes thrombophlebitis unless well diluted
Must be given as an infusion over a minimum of one hour as rapid infusion is associated with arrhythmias and hypotension. Longer infusion periods should be used in patients with risk factors or previous evidence of arrhythmias.

Flucloxacillin
250mg, 500mg & 1g vials
(e.g. Floxapen®)

Add 5ml WFI to 250mg vials
Add 10ml to 500mg vials and 15ml-20ml to 1g vials

NS & G5

IV injection-give slowly over 3-4 minutes
Intermittent IV infusion-dilute in 100ml of compatible infusion fluid and give over 30 minutes

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Fluconazole
200mg in 100ml
(e.g. Diflucan® )

Already in solution

N/A

Intermittent IV infusion-Each 200mg (100ml) should be infused over 10-20 minutes.
Max infusion rate: 20mg per minute.

Each 100ml bag contains 15mmol sodium.

Ganciclovir
500mg vials
(Cymevene®)

Do not administer via rapid or bolus IV injection

Since ganciclovir is considered a potential teratogen and carcinogen in humans, caution should be exercised in its handling .Avoid inhalation or direct contact of the powder contained in the vials or direct contact of the reconstituted solution with the skin or mucous membranes.

Gentamicin
80mg/2ml
(e.g. Genticin®)

Already in solution

NS &G5

IV injection-give slowly over at least 3 minutes. (Bolus not recommended for once daily dosing).

Intermittent IV infusion- Dilute to 100ml of compatible infusion fluid and administer over 20 to 120 minutes.

See aminoglycoside dosing and monitoring section.
Once daily dose should be given by IV infusion.
Monitor plasma concentrations and renal function-dose adjustments required in renal impairment
Flush line before and after administration due to compatibility issues with other drugs, especially penicillin-based injectables

Linezolid
600mg/300ml infusion bag
(Zyvox®)

Already in solution

N/A

Intermittent IV infusion-over 30-120 minutes

Protect from light in protective overwrap until required for use.
Monitor complete blood counts weekly. Approximately 100% bioavailability so should be given by mouth where possible.

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Meropenem
500mg & 1g vials
(Meronem®)

Add 10ml WFI to 500mg vial. Add 20ml WFI to the 1g vial. Allow to stand until solution is clear

NS & G5

IV injection-give slowly over at least 5 minutes
Intermittent IV infusion-dilute in 50-200ml of compatible infusion fluid  and administer over 15-30 minutes

There is limited evidence to support giving a 2g dose as an IV bolus – an IV infusion is recommended for a 2g dose.

Metronidazole
500mg/100ml infusion bags
(Flagyl®)

Already in solution

N/A

Intermittent IV infusion-administer over 20 minutes

Infusion rate should be 5ml/min.
Has very low pH so should not be given as an IV push.

Moxifloxacin
400mg in 250ml bottle
(Avelox®)

Already in solution

N/A

Intermittent IV infusion- administer over an hour

Avoid rapid IV injection.

Piperacillin-tazobactam
(Tazocin®)
4.5g vials

Add 10ml WFI to 2.25g
Add 20ml WFI to 4.5g

NS & G5

IV injection-give slowly over 3-5 minutes

Intermittent IV infusion-dilute in at least 50ml of compatible infusion fluid and give over 20-30 minutes

Rifampicin
600mg vial (+ 10ml diluent)
(Rifadin®)

Add the diluent provided and shake vigorously for 30 seconds

G5 (preferred) & NS

Intermittent IV infusion-dilute in 500ml of compatible infusion fluid and administer over 2-3 hours

Infusion must be completed within 6 hours.
Avoid extravasation.
Will colour all secretions.

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Teicoplanin
200mg & 400mg vials (with diluent)
(Targocid®)

Add the diluent provided slowly and roll the vial gently until dissolved. Do not shake. If foam forms allow to stand for 15 minutes until foam subsides.
A full dose of 200mg or 400mg is obtained  by withdrawing 3ml from the vial.

NS, G5 & Hartmann’s

IV injection-give slowly over 3-5 minutes

Intermittent IV infusion-dilute in 50-100ml of compatible infusion fluid and administer over 30 minutes.

Teicoplanin should be administered with caution to patients with known hypersensitivity to vancomycin since cross reactivity may occur

Tigecycline
50mg vials
(Tygacil®)

Add 5.3ml of infusion fluid (NS or G5) to vial and swirl gently to dissolve. Withdraw 5ml (50mg) from the vial; further dilution required before administration..
For immediate use.

NS & G5

Intermittent IV infusion-dilute required dose in 100ml of infusion fluid and administer over 30-60 minutes

If infusion line is being used for other active substances it must be flushed with NS or G5 before and after infusion.
The reconstituted solution should be yellow to orange in colour; if not, the solution should be discarded. 

Tobramycin
80mg/2ml

Already in solution

NS & G5

IV injection-give slowly over at least 3 minutes. (Bolus not recommended for once daily dosing).

Intermittent IV infusion- Dilute in 50-100ml of compatible infusion fluid and administer over 20 to 60 minutes

See aminoglycoside dosing and monitoring section.
Once daily dose should be given by IV infusion.
Monitor plasma concentrations and renal function-dose adjustments required in renal impairment.

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Vancomycin
500mg & 1g vials

Add 10ml WFI to 500mg vial
Add 20ml WFI to 1g vial

NS & G5

Intermittent IV infusion-dilute each 500mg in at least 100ml of compatible infusion fluid and administer at a rate not faster than 10mg/min

See Vancomycin monitoring appendix for dosing and administration advice.
Administer at rate not faster than 10mg/min to avoid rapid infusion-related reactions including ‘red-man’ syndrome.
Avoid extravasation as may cause tissue necrosis..

Voriconazole
200mg vials
(Vfend®)

Add 19ml WFI to each vial to produce a solution of 10mg/ml solution.  Further dilution is required before administration.

NS, G5 & Hartmann’s

Intermittent IV infusion-dilute dose in a compatible infusion fluid to a concentration between 0.5-5mg/ml. Administer at a rate not exceeding 3mg/kg/hour.

Discard vial if vacuum does not pull diluent into the vial.
In patients with renal impairment, the IV vehicle may accumulate and enhance nephrotoxicity.  The oral route is preferred in these patients. 

(NS =  Sodium  chloride 0.9% / normal saline; G5 = glucose 5%, WFI = water for injection)


References

  1. Summary of Product Characteristics (SPCs) for individual agents: www.medicines.ie and www.medicines.org.uk
  2. British Medical Association: British National Formulary 60 :The Pharmaceutical Press September 2010.
  3. Trissel LA. Handbook on injectable drugs. 15th ed. Bethesda: American Society of Hospital Pharmacists, 2009
  4. UCL Hospitals Injectable Medicines Administration Guide.  2nd ed.  Pharmacy Department, University College London Hospitals 2007