In this article an infectious diseases pharmacist discusses 5 examples where challenging antibiotic workflows can be an issue. 

Authored By: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP

Article Posted October 2024, First Released in the October 2024 IDstewardship Newsletter

1. The time it takes to make a dose of Amphotericin B

Not giving Ambisome today but the order is active as if one is due? Discontinue that order, save a pharmacy tech 15 minutes of wasted time plus avoid tossing an unnecessary dose! Amphotericin products vary, but for example Ambisome comes in 50 mg vials so a 500 mg dose requires 10 vials. Each vial has to be reconstituted and then individually filtered as it goes into the IV bag. That means 10 filters for that one dose! It’s a real pain and a lot of manipulation for the tech. Amphotericin B is also reconstituted in D5W only so that creates workflow challenges as well for nurses who may need D5W for flushing the line before/after the dose. You can read about the preparation here. The final product looks like orange juice.

2. The short expiration date of IV Bactrim

Not only does IV SMX/TMP bring a large volume load of D5W and cause a fair amount of hyperkalemia, it also is a major pain to avoid having it expire. The expiry on a mixed bag depends on the concentration of the dose. Doses of 5 mL per 100 mL D5W should be used within 4 hours of preparation. Doses of 5 mL per 75 mL D5W should be used within just 2 hours of mixing! Remember SMX/TMP is dosed based on mg/kg of the trimethoprim component and should be given over 60-90 minutes. Also fun fact, IV SMX/TMP does not require refrigeration once mixed, so it gets a “DO NOT REFRIGERATE” sticker, at least that is more convenient. Read all about this in the product label here .

3. Special handling of IV ganciclovir

New ganciclovir order at 9 PM is no big deal right? Well, maybe not. Hazardous products such as chemo are prepared under more controlled conditions  than other agents to protect the person making the dose. Go figure a drug with the brand name Cytovene happens to be cytotoxic. Depending on how an IV room pharmacy is set up, certain equipment may have to be turned on, left to run for a time, cleaned, then a dose can be prepared. It’s not a fast process and may even require going to another section of the hospital to complete the work. More information on ganciclovir in the label here .

4. When antibiotic stability varies by product

The same drug at the same dose has the same expiration date all the time, right? Wrong! Products can impact stability. This can relate to premixed bag versus vial or when using certain vial adaptor products to connect a vial directly to a bag. One example is IV meropenem 1 gm duplex containers (like a premixed bag) that must be used within 1 hour once activated if stored at room temperature. Compare that to a 1 gm meropenem vial that once diluted has stability data for 3 hours at room temperature. These types of nuances can create workflow challenges if you are trying to do extended infusions, especially during product shortages.

5. Compounding sulbactam-durlobactam

Admittedly I have never compounded this one myself, but it just sounds like an error waiting to happen as well as a considerable time commitment. To prepare a dose of this product you have to use a kit that includes a clear single-dose of sulbactam 1 gm as well as 2 amber single-dose vials of durlobactam 0.5 gm. The process is detailed in the package insert here . For any site not using SUL/DUR frequently (which is probably many), expect some confusion and added time for the IV room when this order comes in.

Have another one? Put it on X and tag @IDstewardship!

Disclaimer: The views and opinions presented in this article represent those of the author and do not necessarily reflect the policy or position of any previous, current, or potential future employer.

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