Alex J Gregorowicz, Patrick G Costello, David A Gajdosik, John Purakal, Natasha N Pettit, Samantha Bastow, Michael A Ward
OBJECTIVES: Timeliness of antibiotic administration is recognized as an important factor in reducing mortality associated with sepsis. According to guidelines, antibiotics should be administered within 1 hour of sepsis presentation and the Centers for Medicare & Medicaid Services mandates administration within 3 hours. This study evaluates the difference in time from sepsis diagnosis to first-dose completion of β-lactam antibiotics between IV push and IV piggyback administration.
DESIGN: Single-center, retrospective analysis.
SETTING: Urban, tertiary-care emergency department.
PATIENTS: Inclusion criteria were as follows: 1) adult patients (n = 274) diagnosed with severe sepsis or septic shock per Sepsis-2 criteria from September to November 2016 and from September to November 2017 and 2) received β-lactam antibiotic.
INTERVENTIONS: Initial β-lactam agent administered as either IV push or IV piggyback.
MEASUREMENTS AND MAIN RESULTS: Median time (interquartile range) from sepsis diagnosis to administration of a β-lactam antibiotic was 48 minutes (19-96 min) versus 72 minutes (8-180 min) and to administration of the complete broad-spectrum regimen was 108 minutes (66-144 min) versus 114 minutes (42-282 min) in the IV push (n = 143) versus IV piggyback (n = 131) groups, respectively. When controlling for time to sepsis diagnosis and other factors, IV push was associated with approximately 32-minute time savings to β-lactam (β = -0.60; 95% CI, -0.91 to -0.29) and approximately 32-minute time savings to broad-spectrum (β = -0.32; 95% CI, -0.62 to -0.02) antibiotic administrations. The IV push group was less likely to fail the goal of β-lactam antibiotics within 1 hour (44.6% vs 57.3%; odds ratio, 2.27; 95% CI, 1.34-3.86) and 3 hours (7.6% vs 24.5%; odds ratio, 4.31; 95% CI, 2.01-10.28) of sepsis diagnosis compared with IV piggyback. The IV push strategy did not affect mortality, need for ICU admission, or ICU length of stay. No adverse events, including infusion reactions, were found in either arm.
CONCLUSIONS: Use of an IV push strategy may safely facilitate more rapid administration of β-lactam antibiotics and may allow for better compliance with sepsis management guidelines.
Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018; 44:925–928
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589–1596
Howell MD, Davis AM. Management of sepsis and septic shock. JAMA 2017; 317:847–848
McLaughlin JM, Scott RA, Koenig SL, et al. Intravenous push cephalosporin antibiotics in the emergency department: A practice improvement project. Adv Emerg Nurs J 2017; 39:295–299
Garrelts JC, Smith DF, Ast D, et al. A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. Pharmacoeconomics 1992; 1:116–123
Levy MM, Fink MP, Marshall JC, et al.; International Sepsis Definitions Conference: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 2003; 29:530–538
Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in Emergency Department Sepsis (MEDS) score: A prospectively derived and validated clinical prediction rule. Crit Care Med 2003; 31:670–675
Pettit NN, Nguyen CT, Stahle S, et al. Implementing i.v. push administration of piperacillin-tazobactam in response to shortage of small-volume infusion bags. Am J Health Syst Pharm 2018; 75:1358–1359
Garrelts JC, Wagner DJ. The pharmacokinetics, safety, and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother 1999; 33:1258–1261
Tran A, O’Sullivan D, Krawczynski M. Cefepime intravenous push versus intravenous piggyback on time to administration of first-dose vancomycin in the emergency department. J Pharm Pract 2018; 31:605–609
