A question has come up whether it is good practice to infuse two different antibiotics at the same time. They could each be given through a different lumen of a PICC line. Or should they be given one after the other?

I am sure there are studies

I am sure there are studies showing alternative infusion methods for many antibiotics as this is not a new concept. However there are several things in your post that can not be applied to infusion therapy.

The issue of allergic reactions applies to all drugs though. An allergic reaction requires the development of IgE antibodies which requires the person being exposed to the drug for 1 or 2 doses to develop. The subsequent allergic reaction happens with the 3rd, 4th, or more dose. So you can not rule out the possibilty of allergic reaction simply because this is the XX number dose.

Oral, transdermal or other routes of med administration do not have the same considerations as IV. An infusion nurse will be concerned about the drug stability and compatibility and arrive at the best method for infusing multiple drugs. This is most often sequential infusions to avoid any alterations from contact resulting from stability or compatibility issues. This will require consultation with a pharmacist knowledgeable of these issues and not all pharmacists have this knowledge. This information changes frequently and sometimes information from books published annually is outdated. One reference publishes quarterly updates on this information. Without consideration of these factors, your timely administration could result in no clinical improvement because one or more drugs has been rendered ineffective due to the changes from contact with the other drug. Pharmacology, pharmacodynamics and pharmacokinetics are a huge part of infusion nursing. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

ABX

Zosyn,Merepenem and other Beta-lactams are increasingly being given as extended infusions based on evidence that the blood levels attained are more effective at knocking out the offending bugs. I've also given Vanco as a gtt for meningitis and PCN gtt for endocarditis. While I can understand the rationale for sequental ABX administration in some cases,it sounds like being overly cautious and most times impractical. Maybe for the first dose or two to R/O allergic reaction,but not for subsequent administrations. Many is the patient that takes a diuretic,ACE-I and Beta-Blocker every AM for blood pressure control but would you give them one pill every 2 hours in case they might drop their BP??

Even the stopping of a continuous ABX while administering another seems odd.  The half-life of most ABX is such that there is plenty of the med in the blood stream after you hold the gtt,so what would be the point? For another Cardiac analogy,that would be like taking off a pt's NTG patch for a few hours while you give them their Metoprolol.

Also,in the case of severe,life-threatening sepsis,the timely administration of ABX is one of the key recommendations of the Survivng Sepsis campaign (q.v.) and delay of ABX admnistration increases mortality. In such cases a patient may be getting 3-4 ABX plus an antifungal and there will be inevitable overlap in administration times for these meds.

Lynn,I spoke with our

Lynn,

I spoke with our Clinical Coordinator of Pharmacy and these are the reasons and resources she gave me:

 PURPOSE:

Implement the extended infusion dosing strategy of specified beta lactams to optimize the drugs’ pharmacodynamic profile, which can provide beneficial outcomes to patients and provide a consistent dosing regimen throughout the hospital for all patients who are to receive these medications.

REFERENCES:

1.             Drusano GL. Antimicrobial pharmacodynamics: critical interactions of “bug and drug.” Nat Rev Microbiol 2004;2:289-300.

2.             Lodise TP Jr., et.al. Piperacillin-tazobactam for Pseudomonas aeruginosa infection: Clinical implications of an extended-infusion dosing strategy. CID 2007;44:357-363.

3.             Kim MK, Capitano B. Pharmacokinetic and pharmacodynamic evaluation of two dosing regimens for piperacillin/tazobactam.  Pharmacotherapy 2002;22(5):569-577.

4.             Lodise TP Jr., et.al. Application of antimicrobial pharmacodynamic concepts into clinical practice: Focus on Beta-lactam antibiotics.  Pharmacotherapy 2006;26:1321-1332. 

 

Simultaneous administration of antibiotics

This issue is coming up more and more frequently, as some antibiotics that we have always administered intermittently are now being infused continuously in some circumstances.  I am speaking of continuous administration of Vanco, Zosyn, and Ceftriaxone. We are seeing this for cystic fibrosis and osteomyelitis.  We stop the continuous antibiotic while administering a noncompatible second or third antibiotic.  If the antibiotics are compatible, the continuous administration is not stopped.  This is per the directive of the providing pharmacy.  I work in the home care area, and it is always the patients self administering.  I have also seen the simultaneous administration of medications in the area of bone marrow transplant patients who are outpatients after their transplant.  Some of the meds are administered over 4 or more hours, and the Transplant team always choses a LARGE multi lumen line so the patient can administer simultaneously. Frequently hydration is one of the ordered therapies, so whenever possible I have the hydration be the "simultaneously administered" therapy.  

Hallene E Utter, RN, BSN Intravenous Care, INC

2010 edition of Gahart's

2010 edition of Gahart's Intravenous Medications does not include this change. Still says 30 minute infusion every 6, 8 or 12 hours. Do you know the source of this recommendation? Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

We also only allow IV

We also only allow IV antibiotics to be administered sequentially for the exact reasons you mention.  Most recently though a question has arisen.  Due to a recent recommended medication administration time change for Zosyn (to be administered over 4 hours bid or tid), our pharmacists are questioning this practice.  I still stand strong on not administering 2 antibiotics simultaneously but would like some verification of other practices relating to the 4 hour administration time for Zosyn.

They should be infused

They should be infused sequentially and not at the same time. If there is a reaction with simulataneous infusion there is no way to determine which drug caused the reaction. Also, there could be issues with drug stability and compatibility when infused together. Even if you have a dual lumen catheter, I would still recommend sequential infusion. If these intermittent drugs are all that is prescribed, there is no reason for a dual lumen catheter. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861