When and when not to administer intravenous antibiotics

When and when not to administerintravenous antibiotics• Reliable diagnosis of an infection requiring IV rather than oraltherapy as the IV route should only be used if the antibioticcannot be administered by any other route.• IV antibiotic treatment via a peripheral cannula should notnormally exceed two weeks duration, if treatment is expectedto last longer than two weeks a central line or PICC line(Peripherally inserted central catheter) should be considered

Why Antibiotics• Antibiotics are used to treat infectious diseases by killing or inhibitingthe growth of microorganisms.• Antibiotics may be administered orally, intravenously or intramuscularly.• In some patients the absorption of antibiotics taken orally from thegastrointestinal system can be unpredictable and antibiotics may begiven intravenously.• Intravenous administration can cause complications and will also putgreater demands on staff resources.

Benefits of IV Antibiotic Therapy.• Direct administration of antibiotic into the bloodstream allowing tissue penetration quickly.• Levels easily controlled.• Fast acting

Indications for IV Antibiotics

Oral route compromised• Vomiting• Nil by mouth• Severe diarrhoea• Swallowing disorder• Unconscious

Continuing Sepsis2 or more of the following:Temp >38°C or 90bpmRespiratory rate >20 bpmWCC >12 or

Special Indications requiringprolonged high dose IV antibiotics• Endocarditis• Meningitis• Staph. aureus bacteraemia• Immunosuppression• Bone/joint infection• Deep abscess• Cystic fibrosis• Prosthetic infection

Other clinical signs•Febrile with neutropenia•Hypotension/shock:a low blood pressure is associatedwith reduced blood flow to the gutand reduced/unpredictable drugabsorption.•For skin and soft tissue infections:IV therapy indicated if there isheat, erythema and indurationor sepsis syndrome.

Risks of IV Antibiotic Therapy.• Anaphylaxis• Phlebitis – MechanicalChemicalBacterial• Speed Shock• CRBI – Bacteraemia• AKI and liver function

The indications for IV to oral switch• Medication should be changed to oral treatment at theearliest opportunity (usually 3 days). There must be acompletion date or date of review of treatment if needed.• Ideal for pathway treatments such as cellulitis which canachieve an IV to Oral switch much quicker.Usual guidelines include: clinical signs of improvement –• Inflammatory markers, clinical signs, etc.• Haemodynamic stability• Oral route available & working

Guidelines for switchingSelection of oral switch agent also critical and must haveappropriate characteristics• Undertaken under the advice of the Microbiologist• MDT decision• Must have reliable absorption• Must achieve suitable blood levels• No underlying resistance issues

The benefits of oral antibiotics• Reduction in the likelihood of hospital acquired bacteraemia, phlebitis andinfected/IV lines• Patient is more likely to receive antibiotics at the correct time and missfewer doses• Potential reduction in the risk of adverse effects; errors in preparation aresignificantly higher with IV drugs, compared to oral• Reduces patient discomfort and enables improved mobilityand the possibility of earlier discharge from the hospital• Saves both medical and nursing time• Potential reduction in treatment costs allowing

The role of risk assessmentsin IV therapy• Choosing the correct vascular access device– central or peripheral• Know the pH and osmolality of the IV therapy.• Ensuring the patient is not allergic to anycomponent of the treatment• Pathway based treatment to ensure correctactions are undertaken at the correct time.• Awareness of antibiotic resistance• Stop or review dates.

Tips and advice for safe and effective IVtherapy in practice

OPAT Service.• Patients being discharged with IV antibiotics canbe managed in the community by the OPAT team• Save bed days• Better patient experience• Cost saving• Nurse led

Ambulatory Care Pathways• Cellulitis pathway• Admission avoidance• Initially 3 days IV antibiotic bolus• Early oral switch

Multidisciplinary team working• Vascular Access, IV Therapy and OPAT CNS• Infection Prevention and Control CNS• Consultant Microbiologist• Cystic Fibrosis CNS• Clinical team• Medical Day Unit• ED and Minor injury unit• Medical Assessment• Community In-reach

Safe IV Therapy in Practice• Regular IV administration updates for staff• Standardisation of training and practice throughoutthe Trust• Learning form incidents through safer meds group• Proactive approach to poor practice, embracingclinical supervision.• Competency assess high risk IV therapyadministration –TPN• Care bundles for CVC and peripheral cannulas

The Benefits of SuccessfulPeripheral cannulation• Ideal for most IV Antibiotic therapy.• Improve pain initiative outcomes.• Reduce PICC usage based upon more peripheral catheterisations.• Reduce CRBSIs by achieving cannulisation in fewer attempts..• Fewer delays in antibiotic treatments.

Reduce the risk of cannula associatedIV therapy complications• Site cannula with ultrasound or infrared• Site a smaller lumen cannula in the largest veinas far down the arm as possible• Avoid joints and bony prominents.This will avoid chemical, mechanical and bacterial phlebitis andCRBIs.

Vascular Access• Peripheral cannula - Up to a week of IVtherapy, can be discharged on OPAT(indwell time 96hours with VIP 0)• Midline Catheter – up to 6 weeks, IV bolus withpH range 5-9• PICC up to 6 months + - suitable for all IVtherapy• Ports that are in-situ for other therapies can beused (Excluding Parenteral Nutrition)

Other RoutesWhen a patient has an enteral tube (e.g. N/G or PEG) in place, oralantibiotic medication may be considered provided that gastricmotility has been established. Consult microbiology team foradvice.Care must be taken when administering antibiotics via theenteral tube due to the potential for interactions with feeds e.g.ciprofloxacin, flucloxacillin.

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