Summary
As clinicians, our primary objective is to provide the best possible care to our patients. In this pursuit, the administration of short-term intermittent IV antibiotics plays a crucial role in combating infections and saving lives; however, there is an under recognised issue, under delivery, that results in the misuse of antibiotics and could be exacerbating antimicrobial resistance. In this blog, Claire Davies, Clinical Therapy Manager at B. Braun Medical Ltd., explores the issue of under delivery and provides essential insights for clinicians to optimise their antibiotic therapy.
Content
How does under delivery occur?
It’s common practice to administer short-term intermittent IV antibiotics via a pump or gravity administration set. With a gravity system, when the infusion ends and the antibiotic container empties, air is pulled into the line until a state of equilibrium occurs between the fluid level in the line and the back pressure from the patient’s vein. This results in a residual volume of antibiotic remaining trapped in the line of the tube.[1,2]. Similarly, with infusion pump administration, once the programmed infused volume is complete, the infusion line remains filled with the antibiotic.
There is a common misconception that this is resolved by flushing the short extension line (needle-free extension) attached to the patient’s vascular access device post-infusion; however, the residual volume trapped inside the line of the administration set is far more significant than might appear and it can result in an under delivery of the antibiotic dose prescribed of between 20% (100 ml infusion) and 40% (50 ml infusion).[2]
What are the implications of under delivery?
The potential implications of under delivering antibiotics are wide reaching:
Antibiotic resistance
- Resistance is a natural biological phenomenon, but misuse of antibiotics is accelerating the process. For example, the under delivery of antibiotics reduces the likelihood of delivering the expected therapeutic effect resulting in subtherapeutic levels, which could be a significant contributor to the development of resistant strains.[3]
Accumulative effect
- Under delivery is accumulative. A study from one NHS Teaching Hospital highlighted that a patient that was on an antibiotic regime prescribed for 12 weeks, was under delivered 16 ml with each infusion resulting in an accumulative effect of 12 missed doses.[4]
Longer hospital stay
- The accumulative effect of under delivering IV antibiotics could delay the switch to oral, increasing the patient’s length of stay, spend on medication and consumable waste.
How can we overcome this issue
To prevent under delivery and to ensure that the total prescribed dose of IV antibiotic is administered to your patient, a post-infusion flush is needed to infuse the residual volume that is trapped in the line of the IV administration set. The National Infusion and Vascular Access Society has issued a guidance document to provide information regarding the best methods for administering a post-infusion flush:[5]
Method 1: When the antibiotic infusion container has run dry, detach your IV administration set and re-attach the set to a flush container containing a compatible diluent, for example saline. This will enable the trapped residual volume to be infused at the same rate.
Method 2: Use an IV administration set that has an injection port upstream of the drip chamber and when the infusion container has run dry, this will enable attachment of a small volume flush syringe, which again will enable the displacement of the trapped residual volume to be infused at the same rate.
Insights from paediatrics and oncology
"As a paediatric nurse who is now heavily involved in providing infusion therapy management training on a national basis, I was confused to learn that the practice of delivering a post-infusion flush, which is common place in all of the paediatric departments, isn’t replicated in adult nursing". Claire Davies, RN (Child), Clinical Therapy Manager, B. Braun Medical Ltd
"Whilst recently completing my Systemic Anti-Cancer Therapy competency passport, it was immediately evident that there was a strong focus on full dose administration. With costs of treatment being significant and the stakes for patients being high, the practice of flushing the administration line to administer the full dose of medication/treatment is well embedded within oncology. I am hopeful that we will see this practice adopted by other nursing fields to improve the outcomes of all patient groups and to support antimicrobial stewardship." Chelsie Sparks, RN, Clinical Therapy Specialist, B. Braun Medical Ltd
Conclusion
Under delivery of intermittent IV antibiotics may seem like a minor oversight, but its ramifications could be far-reaching. As frontline healthcare professionals, we have a pivotal role to play in ensuring effective antibiotic therapy and by reducing the occurrence of under delivery we can enhance patient outcomes. Together, we can safeguard the efficacy of antibiotics and preserve these for future generations.
References
- Cooper DM, Rassam T, Mellor A. Non-flushing of IV administration sets: an under-recognised under-dosing risk. Br J Nurs. 2018 Jul 26;27(14):S4-S12. doi: 10.12968/bjon.2018.27.14.S4. PMID: 30048183.
- Harding M, Stefka S, Bailey M, et al. Best Practice for Delivering Small-Volume Intermittent Intravenous Infusions. J Infus Nurs. 2020 Jan/Feb;43(1):47-52. doi: 10.1097/NAN.0000000000000355. PMID: 31876774.
- Santillo M. IV Forum; Advancements in IV Administration, 2022.
- Maclachlan L. Antimicrobial Resistance – Importance of flushing the Line to Ensure Total Dose Delivery, 2021.
- National Infusion & Vascular Access Society, Intravenous Administration of Medicines to Adults: Guidance on ‘Line Flushing’, version 3, 2021.
Related reading:
- Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide
- Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT
- How antibiotic underdosing affected my mum’s end of life care: An interview with Ashleigh Hughes
About the Author
Claire Davies is a registered children’s nurse for 23 years. In more recent years, she has been employed in a clinical role in the healthcare industry working in partnership with the NHS to facilitate the achievement of national and local targets with particular interest in patient safety.
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