Momentum Builds for Using IV Push Antibiotics

This article was reviewed by Society of Infectious Diseases Pharmacists committee members Corey Medler, PharmD, MPH, BCIDP; and Meera Mehta, PharmD, BCIDP.

Introduction

Over the past several years, intravenous push (IVP) administration of antimicrobials has gained renewed interest due to its practical advantages in both inpatient and outpatient settings. This rapid drug delivery strategy can be beneficial in time-sensitive scenarios, such as sepsis cases, and is increasingly utilized in the emergency department, where early antibiotic administration is critical for improving clinical outcomes.^1,2 IVP also provides a simplified method for self-administration in outpatient parenteral antimicrobial therapy (OPAT) and helps reduce fluid burden, which is beneficial for patients with volume overload or during IV fluid shortage periods. Despite these benefits, its use also warrants consideration of safety and pharmacologic suitability. This article explores current practices, evidence, and other key factors related to IVP antimicrobial administration.

Clinical and Operational Benefits of IVP

IVP is widely used across care settings due to its operational efficiency. In several small observational studies conducted in emergency departments, the use of IVP significantly decreased the time from antimicrobial ordering to administration.^2-8 Clinical stabilization and the need for intensive care unit (ICU) admission were similar between the IVP and IV piggyback (IVBP) administration groups.^7,9 Agents including ceftriaxone, cefepime, cefazolin, and meropenem have been evaluated across clinical settings, with study findings often demonstrating noninferior clinical efficacy, faster administration times, and comparable safety profiles when delivered via IVP.^2,4 In several observational studies, outcomes such as treatment failure rates, time to clinical stabilization, length of stay, and 30-day readmission rates were similar between IVP and IVPB administration groups.^4,10,11 Additional agent-specific data, including dosing, stability, infusion time, and other clinical considerations, are presented in the Table.

Beyond clinical outcomes, IVP also offers advantages in resource conservation. This is particularly relevant as the availability of necessary materials, such as IV fluid bags, has become a widespread concern during fluid shortages. For example, during the fluid shortage following Hurricane Maria in 2017, one institution was able to conserve 504 L of normal saline over a 6-month period by transitioning to IVP, while maintaining 30-day readmission and mortality rates similar to those with IVPB administration.²² More recently, in the aftermath of Hurricane Helene in 2024, US hospitals implemented conservation strategies, including increased use of IVP, after Baxter International’s North Cove manufacturing plant in Marion, North Carolina, was temporarily closed, disrupting the production of small- and large-volume IV solutions.^22-24

Safety and Adverse Effects

The use of IVP antimicrobials is not without limitations. Due to the more rapid administration, there is concern about increased rates of infusion-related adverse effects (AEs), such as infusion reactions and thrombophlebitis.^8,15,22,23 In one study of 1000 patients receiving IVP β-lactams, only 10 adverse drug effects were observed: 5 allergic reactions, 4 cases of cefepime-related neurotoxicity, and 1 incidence of phlebitis.²² In another study, the rates of overall complications (1.89/1000 catheter days vs 1.69/1000 catheter days) and phlebitis (0.6/1000 catheter days vs 0.79/1000 catheter days) were similar for IVP and minibag plus administration, respectively.¹⁵ Additional safety considerations, specifically regarding medication errors, are addressed by the Institute for Safe Medication Practices to guide medication preparation and administration with regard to IVP medications.^24,25

In addition to general safety concerns, the specific properties of individual antimicrobial agents should also be considered when determining suitability for IVP administration. Several agents pose potential safety concerns when given too quickly; for example, aminoglycosides are not recommended due to the risk of ototoxicity and nephrotoxicity from elevated peak serum levels.²⁶ Similarly, fluoroquinolones can cause venous irritation, hypotension, or QT prolongation.^27-29 Some agents, including certain penicillins (eg, nafcillin, oxacillin) and glycopeptides, require slower infusions to avoid phlebitis, histamine-mediated hypotension, and other infusion-related reactions or complications.^30-32 Other agents, such as imipenem/cilastatin and piperacillin/tazobactam, lack sufficient safety data for rapid administration.

When considering IVP administration, careful review of available literature for stability data, preparation requirements, and AE profiles is recommended. Ideal medications for IVP administration in the outpatient setting should be isotonic, have a near-physiologic pH, and be stable in small volumes for at least 1 week to allow efficient delivery from the pharmacy. However, the required duration of stability may vary depending on institutional protocols and available resources. Antimicrobials with concentration-dependent activity are favored for IVP. Time-dependent antimicrobials may not reach appropriate pharmacodynamic targets, particularly for organisms with higher minimum inhibitory concentrations (MICs).⁹

Pharmacokinetic and Pharmacodynamic Considerations

Pharmacodynamic considerations may influence the choice of administration method, particularly for time-dependent antibiotics such as β-lactams. Because these agents rely on prolonging time above the MIC to achieve optimal efficacy, IVP administration could result in a lower probability of target attainment (PTA) than with standard or extended infusion (EI) strategies. For example, IVP meropenem has been associated with a relatively lower PTA at higher MICs, and additional pharmacokinetic modeling has shown that IVP administration of cefepime may result in lower PTA than intermittent infusion, particularly for organisms with elevated MICs or in patients with altered drug clearance.^10,11,18

With regard to clinical impact, data from one study demonstrated that time to clinical stabilization, defined as resolution of all Systemic Inflammatory Response Syndrome criteria present at the initiation of antimicrobials, was significantly decreased with EI compared with IVP meropenem, suggesting that prolonged exposure may be more effective in critically ill patients.¹¹ Smith et al further reported increased treatment failure with IVP cefepime in critically ill patients, with higher failure rates observed in patients with confirmed infections caused by Pseudomonas aeruginosa.¹⁰ Sherman et al also found that IVP ceftriaxone was associated with significantly higher rates of treatment failure and hospital mortality than IVPB administration in critically ill patients.¹⁸ Conversely, in stable ambulatory patients, self-administration of IVP antimicrobials by patients receiving OPAT allows for faster and simpler administration, lower costs due to less required equipment, and overall higher patient satisfaction.^15,22 Therefore, consideration of infection severity and pathogen susceptibility is important when deciding between IVP and EI for time-dependent agents.

Conclusion

Overall, IVP antimicrobials offer a compelling alternative to traditional infusion delivery methods in a wide range of patient populations. They have been found to be safe and as effective as standard infusions in many observational studies, and they also improve workflow efficiency in settings where rapid, streamlined administration is beneficial. However, caution should be used when considering IVP for patients who are critically ill or at risk for resistant organisms, as meeting adequate pharmacodynamic targets may be more challenging.

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