IV Push Administration for Outpatient Parenteral Antimicrobial Therapy

Intravenous (IV) antimicrobials administered in the outpatient setting, such as outpatient parenteral antimicrobial therapy (OPAT), offer the advantages of shorter hospital length of stay (LOS), prevention of hospital-associated complications, and significant cost savings. They also allow patients to return to activities of daily living with less interruption in their lives compared with prolonged hospitalization to receive IV antimicrobials.¹

In OPAT, IV antimicrobials are typically administered via intermittent IV infusion, which is the generally accepted standard. In contrast, certain medications with a low risk of infusion-related reactions may be given more rapidly via IV push (IVP). Daptomycin, ertapenem, and several cephalosporin antibiotics are commonly administered as IVP in the outpatient setting because of convenience, patient preference, and demonstrated safety profile.^2-11 Although IVP is a common administration method for these selected antimicrobials, there are limited effectiveness data regarding how this translates to OPAT patient-related clinical outcomes.

As a response to the nationwide IV fluid shortage associated with Hurricane Maria, Yagnik and colleagues from Parkland Health in Dallas, Texas, reported on an institutional protocol to transition select medications from IV drip infusion to IVP administration. Their paper details protocol execution and patient outcomes for self-administered IV antibiotics.¹² Parkland Health pharmacists evaluated all self-administered antimicrobials in the outpatient setting for feasibility of IV drip infusion to IVP administration therapeutic interchange for cefazolin, ceftriaxone, cefepime, and daptomycin based on published safety, efficacy, and syringe stability data.

To evaluate OPAT-related outcomes with their IVP administration therapeutic interchange protocol, Yagnik et al designed a quasi-experimental pre- and postintervention analysis comparing a preintervention cohort receiving IV drip antibiotic infusion (November 2016-June 2017) with a postintervention cohort receiving IVP administration (November 2017-June 2018). Included patients had osteoarticular infections and were treated with daptomycin, cefazolin, ceftriaxone, or cefepime. Data were retrospectively extracted from the electronic medical record, including patient demographics and antibiotic treatment regimen.

Evaluated clinical outcomes included hospital LOS, all-cause 30-day and 1-year readmission, 30-day and 1-year emergency department (ED) visits, central line–associated bloodstream infection (CLABSI), and mortality. Additional outcomes evaluated cost comparison data, predischarge medication administration competency assessments, and nurse and patient satisfaction.

The authors evaluated 200 patients, including 95 in the preintervention cohort (IV drip) and 105 in the postintervention cohort (IVP). Patient baseline characteristics were similar between groups, which mostly comprised Hispanic men. The only statistical baseline difference between the groups was patient age (47 +/– 13 years in the IV drop cohort vs 51 +/– 12 years in the IVP cohort; P = .01). The predominant antimicrobials used were ceftriaxone and daptomycin.

Evaluated clinical outcomes demonstrated a significant reduction in median hospital LOS in the IVP cohort compared with the IV drip cohort (11 vs 12 days; P = .03). No differences were seen in 30-day or 1-year all-cause readmission, 30-day or 1-year ED visits, or mortality. No cases of CLABSI were reported in either cohort. Using the predischarge teach-back competency ratio—the number of times administration technique was taught before the patient demonstrated proficiency—the authors showed that IVP administration was easier and faster for patients to learn.

They hypothesized that easier administration may explain the modest reduction in hospital LOS. Among 30 patients who took the patient satisfaction survey, 22 completed the interview, with 21 (95%) preferring IVP administration over IV drip. Cited reasons for IVP preference were reduced administration times, convenience, and clear instructions for administration. In addition to nurse and patient preference, the transition to IVP saved more than 500 L of normal saline and reduced infusion supplies and drug costs, resulting in nearly $45,000 in savings for the institution over the 6-month intervention period. Combined with decreased nursing education time and reduced hospital LOS for IVP patients, an additional $550,000 in costs was avoided.

The study had several limitations introduced by its quasi-experimental design. First, changes in medication and infusion supply–related costs likely decreased over time, which may have artificially inflated cost-savings findings. Additionally, a significantly higher proportion of patients in the IV drip cohort received daptomycin, which carries a higher average wholesale price than the cephalosporin antibiotics used more frequently in the IVP cohort. Second, although the IVP cohort demonstrated proficiency at medication administration more quickly than the IV drip cohort, it seems improbable that an additional teaching session would delay discharge by a full calendar day. It is likely that increased efficiencies in other steps of the discharge process, likely unrelated to the teaching and unaccounted for in this study, also contributed to a timelier discharge.

This study is one of the first to date examining the clinical, financial, and patient impact of IVP administration of antibiotics in the OPAT setting. With comparable clinical outcomes, the results demonstrate that IVP antibiotics are a reasonable alternative to IV drip administration in times of fluid shortages. In addition, documented patient preference and obvious financial incentives demonstrate a clear role for IVP administration in everyday OPAT practice.

Highlighted Study

Yagnik KJ, Brown LS, Saad HA, et al. Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria. Open Forum Infect Dis. 2022;9(5):ofac117. Published 2022 Mar 21. doi:10.1093/ ofid/ofac117

References

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8.McLaughlin JM, Scott RA, Koenig SL, Mueller SW. Intravenous push cephalosporin antibiotics in the emergency department: a practice improvement project. Adv Emerg Nurs J. 2017;39(4):295-299. doi:10.1097/TME.0000000000000160

9.Marsh K, Ahmed N, Decano A, et al. Safety of intravenous push administration of beta-lactams within a healthcare system. Am J Health Syst Pharm.2020;77(9):701-708. doi:10.1093/ajhp/zxaa044

10.Corrado MJ, Riselli A, McLaughlin KC, Szumita PM, Anger KE. Safety of intravenous push ertapenem compared to intravenous piggyback at a tertiary academic medical center. J Pharm Pract.Published online August 12, 2021. doi:10.1177/08971900211038355

11.Gill CM, Kenney RM, Makowski CT, Davis SL. High-dose daptomycin is well tolerated via 2-minute IV push administration. Hosp Pharm. 2021;56(4):328-331.doi:10.1177/0018578719897076

12.Yagnik KJ, Brown LS, Saad HA, et al. Implementation of IV push antibiotics for outpatients during a national fluid shortage following Hurricane Maria. Open Forum Infect Dis.2022;9(5):ofac117. doi:10.1093/ofid/ofac117