PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: benzathine benzylpenicillin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Use a concentration of 442 mg/mL when measuring part doses.
• Usually use undiluted.
• Some sources recommend adding lidocaine to the prefilled syringe (reduces pain at injection site) ^12,13.
  • Draw up 0.25 mL lidocaine 2% using a filter needle attached to a 1 mL syringe.
  • Remove filter needle and replace with 22G or 23G needle in syringe containing lidocaine.
  • Remove cap from prefilled Bicillin L-A syringe and draw back to allow space at tip of syringe.
  • Add 0.25 mL lidocaine 2% to Bicillin L-A syringe.
  • Push Bicillin L-A plunger up gently and slowly until medication reaches the tip of the syringe.
  • Attach a 22G needle for administration.

Injection solution properties and stability:

• Single patient use only. Discard any unused portion.

Administration notes:

• ENSURE IT IS THE CORRECT PRODUCT. Benzylpenicillin (or penicillin G) is available as the benzathine salt (benzathine benzylpenicillin for IM injection only ? this preparation), the sodium salt (benzylpenicillin sodium for IV and IM injection), the procaine salt (procaine benzylpenicillin for IM injection only).
• Warm to room temperature before administration.
• Aspirate before injecting to ensure that the needle is not in a blood vessel. If blood appears, withdraw and inject at another site.
• Administer doses greater than 900 mg at 2 separate injection sites ⁷.
• Inject by deep injection in the upper, outer quadrant of the buttock.
• Administer at a slow, steady rate to avoid blockage of the needle by the suspended content
• Avoid injection into or near major peripheral nerves or blood vessels, as this may cause neurovascular damage.
• Injection may be painful ? apply ice ¹¹ or a vibrating ice pack (Buzzy) ¹³ to the injection site to alleviate pain and discomfort.
• Rotate injection sites for repeated doses.

MONITORING/OBSERVATION/CAUTION

• Observe for early signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor renal, hepatic and haematologic function periodically with prolonged therapy.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Bicillin L-A [Medsafe Datasheet]. Pfizer New Zealand Ltd, 08 June 2012
2. New Zealand Formulary. Benzathine benzylpenicillin [Accessed 20 June 2015]
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 20 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6^th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
11. Lippincott. Nursing 2015 Drug Handbook. 35^th ed. Wolters Kluwer, 2014
12. Administration of IM lignocaine & Bicillin. [Accessed via Norther Region Clinical Pathways http://www.healthpointpathways.co.nz/assets/RF/IM_BICILLIN_Administration_Procedure_with_glass_ampoule%20pdf1.pdf?v=14347 85890048 / 20 June 2015]
13. Russell K, Nicholson R, Naidu R. Reducing the pain of intramuscular benzathine penicillin injections in the rheumatic fever population of Counties Manukau District Health Board. J Paediatr Child Health 2014; 50(2):112-7 [Accessed via PubMed http://www.ncbi.nlm.nih.gov/pubmed/24134180 / 20 June2015]

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ datasheet

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Use undiluted.

Injection solution properties and stability:

• Single use only. Discard any unused portion.

Administration notes:

• ENSURE IT IS THE CORRECT PRODUCT. Benzylpenicillin (or penicillin G) is available as the procaine salt (procaine benzylpenicillin for IM injection only ? this preparation), the sodium salt (benzylpenicillin sodium for IV and IM injection), the benzathine salt (benzathine benzylpenicillin for IM injection only).
• Warm to room temperature before administration.
• Aspirate before injecting to ensure that needle is not in a blood vessel. If blood appears, withdraw and inject at another site.
• Administer by deep injection in the upper, outer quadrant of buttocks¹¹.
• Administer at a slow, steady rate to avoid blockage of the needle by the suspended content ⁵.
• Do not massage injection site ¹¹
• Avoid injection into or near major nerves or blood vessels, as this may cause neurovascular damage and tissue necrosis ¹¹
• Injection may be painful ? apply ice to the injection site to alleviate pain and discomfort ¹¹.
• Rotate injection site for repeated doses ^4,5,11.

MONITORING/OBSERVATION/CAUTION

• Observe for early signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor renal and haematologic function periodically with prolonged therapy ^4,11

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Cilicaine [Medsafe Datasheet]. Pharmacy Retailing (NZ) Limited, 13 February 2013
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 22 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: aciclovir.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTRAMUSCULAR INJECTION:

Infusion solution concentration and preparation:

• Reconstitute each 250 mg vial with 10 mL of either water for injection or 0.9% sodium chloride concentration (~ 25 mg/mL). Shake well to ensure complete dissolution of the drug.
• Draw up appropriate dose. The reconstituted solution may be infused (reserved for fluid restricted patients) or further diluted.
• Further dilute with a compatible IV fluid to a concentration of 5 mg/mL or less.
  • For doses between 250 mg and 500 mg: add to one 100 mL infusion bag
  • For doses between 500 mg to 1,000 mg: divide dose and add to two 100 mL infusion bags.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Lactated Ringer?s (Hartmann?s)
• Others: Glucose/sodium chloride combinations, Sodium chloride 0.45%. AVOID: Biological or colloidal fluids ⁷.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information on drug incompatibilities or compatibilities.
• Other sources recommend some drug compatibilities 7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.
• Discard any unused portion.
• Visually inspect for turbidity or crystallisation; do not use if present.

Administration notes:

• Confirm patency of vein ? avoid extravasation (highly alkaline).
• Infuse diluted solution (5 mg/mL or less) over at least 1 hour (risk of tubular necrosis/renal damage with rapid infusion ^3,4,7,9,11).
• Rotate site of infusion ^4,9.
• Reconstituted solution (25 mg/mL) may be given over at least 1 hour via an infusion pump ^6,8.
  • Using concentrations greater than 7 mg/mL increases the risk of phlebitis and inflammation at the infusion site and should only be used in fluid restricted patients with central venous access^5,6,7.

MONITORING/OBSERVATION/CAUTION

• Maintain adequate hydration and urine flow before and during infusion (minimise risk of renal toxicity) ^9,11.
• Monitor creatinine and blood urea levels along with urine output during treatment ^9,11.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Zovirax [Medsafe Datasheet]. GlaxoSmithKline NZ Ltd, 10 October 2014
2. New Zealand Formulary. Aciclovir [Accessed 13 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 13 June 2015] 7
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014 8
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.4 13 Feb 2014). United Kingdom Clinical Pharmacy Association; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014.
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013.
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014.

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: amikacin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Prepare infusion solution by adding appropriate dose to 100 to 200 mL compatible IV fluid; recommended concentration 0.25 to 5 mg/mL; minimum volume of 50 mL is suggested ⁸.
• The final concentration of diluted solution for infusion is dose-related, e.g. higher doses and once-daily regimens may necessitate higher concentrations ? consult local protocols.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer?s (Hartmann?s) ^7,9
• Others: Glucose/sodium chloride combinations ⁷; glucose 10% ⁷, mannitol ^7,10, Plasmalyte ⁹, Ringer?s, mannitol ¹⁰.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Amikacin should not be physically mixed with other drugs in the same infusion solution or infused simultaneously through the same tubing.
• Amikacin is inactivated by solutions containing penicillins; it is recommended that amikacin and penicillin doses are administered separately and at different sites to avoid mixing these medications in administration lines.
• Other sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare solution immediately before use. If storage is required, see 'Storage' above.
• Use diluted solutions within 12 hours after preparation.

Administration notes:

• Peripheral vein or central line.
• Administer over 30 to 60 minutes.
• Flush line after infusion to ensure full dose is delivered.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Use undiluted (250 mg/mL) ⁵.
• May be diluted if required to improve accuracy of drawing up the correct dose.

Compatibility ? Diluents for IM administration if dilution required:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%.

Injection solution properties and stability:

• Draw up (or if diluted prepare) solution immediately before use.
• Use diluted solutions within 12 hours after preparation.

Administration notes:

• Inject deep into large muscle mass, e.g. gluteal muscle or lateral part of thigh ^4,5.
• Avoid injecting into a blood vessel.

MONITORING/OBSERVATION/CAUTION

• Monitor for hypersensitivity/anaphylaxis to drug and any excipients ? contains sulfites. Sulfite sensitivity more likely in asthmatic patients.
• Do not use in patients with previous hypersensitivity or serious nephrotoxic and/or ototoxic reactions to any aminoglycoside.
• Avoid concomitant use with other antibiotics or potent diuretics that also may enhance neurotoxicity and/or nephrotoxicity.
• Use with caution in patients with muscular disorders, e.g. myasthenia gravis or Parkinson?s disease (may aggravate muscle weakness).
• Prior to therapy, assess renal function (where possible) and obtain specimen for culture and sensitivity ¹¹.
• Monitor IV site regularly and rotate injection site to reduce risk of local irritation and pain.
• Correct dehydration before initiating therapy and maintain adequate hydration throughout therapy (minimises irritation of or damage to renal tubules) ^1,11.
• Notify prescriber if patient develops tinnitus, vertigo or hearing impairment. Monitor auditory and vestibular function weekly, particularly in patients undergoing prolonged or repeated therapy ^9,11.
• Monitor renal function and urinary output daily ⁹.

Therapeutic Drug Monitoring:

• Amikacin plasma concentrations should be monitored periodically to optimise efficacy and reduce toxicity, particularly in patients with renal impairment.
• Consult local hospital guidelines for frequency of monitoring and times post dose to draw levels. These will vary according to dosing interval and renal status:
  • peak levels draw specimen usually 30 minutes after completion of an IV infusion or 1 hour following intramuscular injection.
  • mid-dosing levels (as per some hospital guidelines) take a level 6 to 24 hours post dose depending on patient?s renal function and dosing interval.
  • trough levels draw specimen as close as practicable prior to next dose, e.g. within 30 minutes ^4,11. It is often not necessary or practicable to have the level back before the next dose is administered, however, the level may be used to adjust subsequent doses.

• Draw approximately 5 mL of venous blood from a peripheral site (avoids antibiotic contamination).

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. DBL^TM Amikacin Injection [Medsafe Datasheet]. Hospira NZ Limited, 19 August 2014.
2. New Zealand Formulary. Amikacin [Accessed 15 June 2015].
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014.
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 15 June 2015].
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6^th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4^th ed. (v4.4, Feb 2014). United Kingdom Clinical Pharmacy Association; 2012.
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014.
10. Trissel LA. Handbook on Injectable Drugs. 17^th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013.
11. Lippincott. Nursing 2014 Drug Handbook. 34^th ed. Wolters Kluwer, 2014.

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: amphotericin B.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Recommended final concentration ranges between 0.2 mg/mL to 2 mg/mL.
  • Some centres have used 4 mg/mL via central line ⁸.
• Reconstitute using only water for injection by:
  • adding 12 mL water for injection to 50 mg vial (concentration 4 mg/mL).
• Shake the vial vigorously for at least 30 seconds to disperse completely.
• Visually inspect for particulate matter. Continue shaking until complete dispersion is obtained.
• Dilute further by withdrawing the appropriate dose from the reconstituted solution and injecting it through the 5 micron filter supplied with each vial into glucose 5% (DO NOT use sodium chloride) to make a final concentration between 0.2 and 2 mg/mL, e.g.:
  • 50 mg in minimum total volume 25 mL (2 mg/mL).
  • 50 mg in maximum total volume 250 mL (0.2 mg/mL).
• Use a 5 micron filter (supplied) for transfer. Use a new filter for each vial.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Glucose (dextrose) 5%
  AVOID: Sodium chloride 0.9%.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information on drug incompatibilities or compatibilities.
• Other sources recommend a limited range of drug compatibilities 9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see ?Storage? above.
• Visually inspect for particulate matter. Do not use if present.

Administration notes:

• ENSURE IT IS THE CORRECT PRODUCT. Amphotericin B products are not interchangeable and conventional amphotericin B must be infused over a much longer period ^2,9.
• Central line preferred, particularly for stronger concentrations.
• An in-line filter may be used for IV infusion, however a mean pore diameter of the filter SHOULD NOT be less than 1 micron, as this may filter out the active ingredient.
• Administer via an infusion pump.
• Infuse over 30 to 60 minutes.
• Some sources cite an initial infusion duration of 2 hours, reducing to approximately 1 hour in patients in whom the treatment is well tolerated ^4,9,11.
• Flush existing IV line with glucose 5% before and after infusing drug. If not possible, infuse through a separate line ¹¹.

MONITORING/OBSERVATION/CAUTION

• Ensure adequate hydration to reduce the risk of nephrotoxicity ^9,11
• Monitor for hypersensitivity/anaphylaxis
• Monitor for signs of infusion-related reactions; most common are fever, rigors, chills and back pain. If they occur, stop the infusion and consider restarting at a lower infusion rate. Consider a longer infusion time up to 2 hours for subsequent doses.
• Monitor vital signs every 30 minutes for up to 4 hours after infusion is complete ⁹.
• Monitor for signs of hypokalaemia and hypomagnesaemia (muscle weakness, cramping or drowsiness) ¹¹.
• Monitor renal, hepatic and haematologic function at baseline and periodically during therapy.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Ambisome [Medsafe Datasheet]. Gilead Sciences NZ, 10 September 2014
2. New Zealand Formulary. Amphotericin B [Accessed 12 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014.
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014.
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 12 June 2015].
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.2 May 2013). United Kingdom Clinical Pharmacy Association; 2012.
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014.
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013.
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014.

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: amoxicillin + clavulanic acid.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding an appropriate volume of compatible diluent for IV injection to vial

  Reconstituted solution strength	Vial Size
  	600 mg	1.2 mg
  Complete vial use	10 mL	20 mL
  Part vial use ~ 60 mg/mL	9.5 mL	19 mL

• Agitate vial until powder is dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use, and use within 20 minutes of reconstitution.
• Discard any unused reconstituted solution.

Administration notes:

• Inject slowly over 3 to 4 minutes.
• May be injected directly into vein or via a drip tube.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Reconstitute as for direct IV injection and dilute further by adding required dose to suitable
  volume of compatible IV fluid:
  • 600 mg to 50 mL.
  • 1.2 g to 100 mL.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Lactated Ringers (Hartmann?s).
  AVOID: glucose (dextrose), dextran or sodium bicarbonate.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer recommends amoxicillin plus clavulanic acid should NOT be mixed with blood products, proteinaceous fluids or lipid emulsions.
• Limited data is available regarding drug incompatibilities or compatibilities ¹⁰. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use, and use within 60 minutes of preparation. However, if storage is required, see ?Storage? above.
• For refrigerated solutions, prepare with chilled diluent and use immediately when the solution attains room temperature.

Administration notes:

• Infuse slowly over 30 to 40 minutes.
  DOSE TABLE ? check your calculation

  Amoxicillin + clavulanic acid - dose conversion chart: gram/hour to mL/hour
  			Dose	Example
  		600 mg infused over 40 minutes	600 mg infused over 30 minutes	1.2 g infused over 40 minutes	1.2 g infused over 30 minutes
  			Dose rate in	g/h
  		0.9	1.2	1.8	2.4
  Infusion solution concentration		Convert to
  			Dose rate in	mL/h
  12 mg/mL	600 mg in 50 mL	75	100	-	-
  12 mg/mL	1.2 g in 100 mL	-	-	150	200

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before first dose.
• Monitor renal, hepatic and haematologic function periodically during prolonged therapy.
• Ensure adequate hydration and urinary output in patients receiving high doses to reduce the risk of amoxicillin crystalluria.
• Observe infusion site for thrombophlebitis. Change site every 48 hours.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Amoxiclav [Medsafe Datasheet]. Multichem NZ Limited, 04 April 2012
2. New Zealand Formulary. Amoxicillin + clavulanic acid [Accessed 20 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013

REFERENCES

1. Product information. AusDI [Internet]. Sydney: Phoenix Medical Publishing; 2006. Updated 02/08/13. Accessed 22/08/13.
2. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, Maryland: American Society of Health System Pharmacists; 2013.
3. Royal Children?s Hospital Pharmacy Department. Paediatric injectable guidelines. 4th ed. Flemington, Vic: The Royal Children?s Hospital; 2011.
4. Taketomo C, Hodding J, Kraus D. Paediatric and neonatal dosage handbook. 19th ed. Hudson, Ohio: American Pharmacists Association. Lexicomp; 2012.
5. Phelps SJ, Hageman TM, Lee KR, Thompson AJ. Paediatric injectable drugs. The teddy bear book. 10th ed. Bethesda, Maryland: American Society of Health System Pharmacists; 2013.
6. Ampicillin. In: IV index. Trissel's 2 clinical pharmaceutics database (parenteral compatibility). Greenwood Village, Colorado: Truven Health Analytics. Accessed 21/02/11.

REFERENCES

1. Product information. AusDI [Internet]. Sydney: Phoenix Medical Publishing; 2006. Updated 02/08/13. Accessed 26/08/13.
2. Anidulafungin. In: IV index [Internet]. Trissel's 2 clinical pharmaceutics database (parenteral compatibility). Greenwood Village, Colorado: Truven Health Analytics. Accessed 26/08/13.
3. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, Maryland: American Society of Health System Pharmacists; 2013.

REFERENCES

1. Product information. AusDI [Internet]. Sydney: Phoenix Medical Publishing; 2006. Updated 02/08/13. Accessed 29/08/13
2. Phelps SJ, Hageman TM, Lee KR, Thompson AJ. Paediatric injectable drugs. The teddy bear book. 10th ed. Bethesda, Maryland: American Society of Health System Pharmacists; 2013.
3. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, Maryland: American Society of Health System Pharmacists; 2013.
4. Azithromycin. In: IV index. Trissel's 2 clinical pharmaceutics database (parenteral compatibility). Greenwood Village, Colorado: Truven Health Analytics. Accessed 29/09/10.
5. McEvoy GK. editor. AHFS 2013 drug information. Bethesda, Maryland: American Society of Health System Pharmacists; 2013

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring toNZ Formulary: amoxicillin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV administration to vial.

  Reconstituted solution strength.	Vial Size
  	250 mg	500 mg	1 g
  Complete vial use	5 mL	5 mL to 10 mL 1,10	5 mL to 20 mL 1,10
  Part vial use ~ 50 mg/mL	4.8 mL	-	-
  Part vial use ~ 100 mg/mL	-	4.6 mL	-
  Part vial use ~ 200 mg/mL	-	-	4.2 mL

• Shake vigorously until all the powder is dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter. Do not use if present.

Administration notes:

• Inject into peripheral vein or central line slowly over 3 to 4 minutes, preferably longer for higher doses. Some sources recommend not exceeding a rate of 100 mg/minute ¹¹.
• May be injected into side arm of a compatible infusion solution.
• Rapid IV administration may result in seizures ⁷.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Reconstitute solution as for direct IV injection then further dilute by adding required dose to 50 to 100 mL of compatible IV fluid.
• Concentrations of 50 mg/mL are substantially less stable than those at 10 to 20 mg/mL ¹⁰.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)

AVOID: Solutions containing carbohydrate, e.g. glucose - amoxicillin sodium is less stable.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer recommends amoxicillin should NOT be mixed with blood products, proteinaceous fluids or lipid emulsions.
• Limited data is available regarding drug incompatibilities or compatibilities ^7,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter. Do not use if present.

Administration notes:

• Infuse over 30 to 60 minutes.
• Infuse via peripheral or central line.
• DOSE TABLE ? check your calculation

  Amoxicillin - dose conversion chart: gram/hour to mL/hour
  			Dose	Example
  		500 mg infused over 1 hour	infused over 1 hour 500 mg over 30 minutes or 1 g over 1 hour	1 g infused over 30 minutes or 2 g infused over 1 hour	2 g infused over 30 minutes
  			Dose rate in	g/h
  		0.5	1	2	4
  Infusion solution concentration		Convert to
  			Dose rate in	mL/h
  5 mg/mL	500 mg in 100 mL	100	200	-	-
  10 mg/mL	500 mg in 50 mL	50	100	-	-
  10 mg/mL	1 g in 100 mL	50	100	200	-
  20 mg/mL	1 g in 50 mL	-	50	100	-
  20 mg/mL	2 g in 100 mL	-	-	100	200
  40 mg/mL	2 g in 50 mL	-	-	50	100

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IM administration to vial.

  Reconstituted solution strength.	Vial Size
  	250 mg	500 mg	1 g
  Complete vial use	5 mL	5 mL to 10 mL 1,10	5 mL to 20 mL 1,10
  Part vial use ~ 50 mg/mL	4.8 mL	-	-
  Part vial use ~ 100 mg/mL	-	4.6 mL	-
  Part vial use ~ 200 mg/mL	-	-	4.2 mL

• Shake vigorously until all the powder is dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection (may be painful)
• Other: Lignocaine 1%.

Injection solution properties and stability:

• Prepare immediately before use. Use prepared injection within 1 hour.

Administration notes:

• Inject by deep intramuscular injection into large muscle ⁷.
• Doses larger than 500 mg should be divided and injected at more than one site ⁷.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis ^4,9.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor renal, hepatic and haematologic function periodically, with prolonged therapy ^4,9.
• Ensure adequate hydration and urinary output in patients receiving high doses to reduce the risk of amoxicillin crystalluria.
• Observe infusion site for thrombophlebitis 9. Change site every 48 hours ¹¹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Ibiamox [Medsafe Datasheet]. Douglas Pharmaceuticals, 06 October 2011
2. New Zealand Formulary. Amoxicillin [Accessed 20 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ Accessed 20 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
12. Personal communication. Sodium content in Ibiamox preparations. Data on file. Douglas Pharmaceuticals, 16 July 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: aztreonam.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding an appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength.	Vial Size
  	1 g
  Complete vial use	6 to 10 mL
  Part vial use ~100 mg/mL	8.8 mL 7

• Immediately shake the vial vigorously until all the powder is completely dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use.
• Discard any unused solution.

Administration notes:

• Inject slowly over 3 to 5 minutes.
• Administer directly into vein or IV tubing ¹¹.
• Flush before and after administration.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration not to exceed 20 mg/mL (2% w/v).
• Reconstitute as for direct IV injection and dilute further with at least 50 mL of compatible IV fluid per gram of aztreonam, e.g.:
  
  • 0.5 g in 50 mL (10 mg/mL)
  • 1 g in 50 mL (20 mg/mL)
  • 1.5 g in 100 mL (15 mg/mL)
  • 2 g in 100 mL (20 mg/mL).

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose/sodium chloride combinations, Mannitol, Ringer's.

Compatibility ? Drugs in the same infusion solution or Y-site:

• The manufacturer states that aztreonam should not be admixed with other drugs or antibiotics, and when administering drugs via a common administration set flush before and after delivery with an infusion solution that is compatible with both drugs.
• Other sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse over 20 to 60 minutes.
• Administer via a large vein.
• Flush IV tubing before and after administration.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute 1 gram vial by adding 3 mL of compatible diluent for IM injection.
• Immediately shake the vial vigorously until all the powder is completely dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection
• Sodium chloride 0.9%.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Any unused solution must be discarded.

Administration notes:

• Inject deep into a large muscle mass (such as upper, outer quadrant of the gluteus maximus or the lateral part of the thigh).
• Usually well tolerated, and should not be admixed with a local anaesthetic agent ^1,5.

MONITORING/OBSERVATION/CAUTION

• Monitor for hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before the first dose.
• Monitor renal and hepatic function periodically.
• Monitor injection site for signs of thrombophlebitis. Use small needles and large veins, and change injection/infusion sites regularly ⁹.
• Observe for changed bowel frequency ? risk of colitis.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Azactam [Medsafe Datasheet]. Bristol-Myers Squibb (NZ) Limited, 1 October 2013
2. New Zealand Formulary. Aztreonam [Accessed 14 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 14 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: benzylpenicillin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• A final concentration of 60 mg/mL is isotonic.
• Reconstitute by adding appropriate volume of compatible IV diluent to the vial.

  Reconstituted solution strength.	Vial Size
  	600 mg (displacement 0.4 mL)
  Complete vial use ~ 60 mg/mL	9.6 mL (isotonic)
  Partial vial use ~ 150 mg/mL	3.6 mL
  Partial vial use ~ 200 mg/mL	2.6 mL
  Partial vial use ~ 300 mg/mL	1.6 mL

• Rotate the vial while adding water for injection slowly, directing the stream against the wall of the vial ^9,10.
• Shake the vial vigorously until dissolved ¹⁰.

Compatibility ? IV fluids appropriate to dilute IV injection:

• Water for injection
• Glucose (dextrose 5%) ⁷.
  AVOID: Sodium chloride 0.9%, Lactated Ringer's (Hartmann's), Ringer's (sodium containing fluids are not recommended as diluents due to their additional electrolyte content ⁷).

Infusion solution properties and stability:

• Prepare immediately before administration ? rapid degradation in solution (unless buffered).
• Discard any unused reconstituted solution.

Administration notes:

• Inject slowly over 3 to 10 minutes, maximum rate 300 mg/minute ⁷.
• For doses greater than 6 grams daily, alternate injection sites every 2 days (to prevent superinfections and thrombophlebitis).

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Reconstitute as for direct IV injection.
• Dilute further by adding the required dose to 50 mL to 100 mL of compatible IV fluid ^4,9.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Water for injection
• Glucose (dextrose 5%) ⁷
• Sodium chloride 0.9% ? provided the benzylpenicillin dose not too high (potential to enhance electrolyte imbalances).

AVOID: Lactated Ringer's (Hartmann's), Ringer's.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Benzylpenicillin sodium is readily destroyed by oxidising agents, reducing agents, alkaline or acidic solutions (pH outside 5.4 to 8.5), and salts of easily reducible metals, e.g. iron, copper, zinc.
• Manufacturer states the following specific drug incompatibilities: cimetidine, cytarabine, chlorpromazine, dopamine and other sympathomimetic amines, heparin, lincomycin, metaraminol, sodium bicarbonate, thiopental sodium, vancomycin, vitamin B and C complex. This list is not comprehensive.
• Other standard sources recommend some drug compatibilities 9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before administration ? rapid degradation in solution.
• Discard any unused reconstituted or diluted solution.

Administration notes:

• Infuse over 30 to 60 minutes; sometimes up to 120 minutes ^4,6,7,11.
• DOSE TABLE ? check your calculation

  Benzyl penicillin sodium - dose conversion chart: gram/hour to mL/hour
  		Dose Example
  		600 mg over 30 minutes or 1.2 g over 60 minutes	1.2 g over 30 minutes or 2.4 g over 60 minutes	1.5 g over 30 minutes or 3 g over 60 minutes	2.4 g over 30 minutes	3 g over 30 minutes or 6 g over 60 minutes
  		Dose rate in g/h
  		1.2	2.4	3	4.8	6
  Infusion solution concentration		converts to Dose rate in mL/h
  		6 mg/mL	600 mg in 100 mL	200	-	-	-	-
  12 mg/mL	600 mg in 50 mL	100	200	-	-	-
  12 mg/mL	1.2 g in 100 mL	100	200	-	-	-
  24 mg/mL	1.2 g in 50 mL	50	100	-	-	-
  24 mg/mL	2.4 g in 100 mL	-	100	-	200	-
  30 mg/mL	1.5 g in 50 mL	-	-	100	-	-
  30 mg/mL	3 g in 100 mL	-	-	100	-	200

• For doses greater than 6 grams daily, alternate injection sites every 2 days (to prevent superinfections and thrombophlebitis).

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Recommended concentration is about 300 mg/mL.
• Reconstitute by adding appropriate volume of compatible diluent for IM administration.

  Reconstituted solution strength.	Vial Size
  	600 mg (displacement 0.4 mL)
  Complete vial use	2 mL
  Partial vial use ~ 300 mg/mL	1.6 mL

• Rotate the vial while adding water for injection slowly, directing the stream against the wall of the vial ^9,10.
• Shake the vial vigorously until dissolved 10.

Compatibility ? Diluents for IM administration:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before administration ? rapid degradation in solution.
• Discard any unused solution.

Administration notes:

• Administer by deep injection in the upper outer quadrant of the buttock or Hochstetter's ventrogluteal field.
• Administer up to 5 mL of solution per injection site. Use alternative injection sites for repeated injections.
• Do not administer doses of more than 6 grams twice daily intramuscularly.
• Injection may be painful ? apply ice to the injection site to alleviate pain and discomfort ¹¹.
• Consider the delayed absorption from the IM depot in diabetics.

MONITORING/OBSERVATION/CAUTION

• ENSURE IT IS THE CORRECT PRODUCT. Benzylpenicillin (or penicillin G) is available as the sodium salt (benzylpenicillin sodium for IV and IM injection - this preparation), the benzathine salt (benzathine benzylpenicillin for IM injection only), the procaine salt (procaine benzylpenicillin for IM injection only).
• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis and for 30 minutes after administration.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor electrolytes, and renal, hepatic and haematologic function periodically during prolonged therapy.
• Observe for changes bowel frequency ? risk of pseudomembranous colitis with prolonged therapy.
• For dose of more than 10 MU, consider a continuous infusion to prevent potential electrolyte imbalances, and for doses greater than 20 MU to avoid potential convulsions ¹⁰.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Penicillin G Sodium [Medsafe Datasheet]. Novartis, 09 December 2014
2. New Zealand Formulary. Benzylpenicillin [Accessed 20 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 20 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: caspofungin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Remove vial from fridge, and allow to reach room temperature.
• Reconstitute by adding 10.5 mL water for injection or sodium chloride 0.9%.
• Mix gently until completely dissolved producing a clear solution.
• Concentration of reconstituted solution is:
  • 7.2 mg/mL (70 mg vial)
  • 5.2 mg/mL (50 mg vial).
• Further dilute the required dose from the reconstituted solution to 250 mL compatible IV fluid.
  • A reduced volume (100 mL) may be used for 50 mg or 35 mg doses only.

Compatibility ? Diluent appropriate to RECONSTITUTE solution:

• Sodium chloride 0.9%
• Water for infection.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Lactated Ringer?s (Hartmann?s).
• AVOID: Glucose-containing solutions ⁸.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information regarding drug incompatibilities or compatibilities.
• Other sources recommend a range of drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Stable when stored at room temperature (below 25?C) for up to 24 hours, or when refrigerated (between 2?C and 8?C) for up to 48 hours.

Administration notes:

• Infuse slowly over 1 hour.

MONITORING/OBSERVATION/CAUTION

• Monitor for possible allergic type reaction during infusion (rash, flushing, pruritus, facial oedema) ^4,11.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Cancidas? [Medsafe Datasheet]. Merck Sharp & Dohme (New Zealand) Limited, 03 October 2014
2. New Zealand Formulary. Caspofungin [Accessed 22 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 22 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.2 May 2013). United Kingdom Clinical Pharmacy Association; 2012
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cefepime.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible IV diluent to vial.

  Reconstituted solution strength	Vial size
  	1 g	2 g
  Complete vial use ~88 mg/mL	10 mL	-
  Complete vial use ~158 mg/mL	-	10 mL
  Partial vial use ~100 mg/mL	8.7 mL 7	17.4 mL 7

• Shake gently until dissolved.

Compatibility ? Diluents for direct IV injection:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%.

Injection solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.
• Inspect visually for particulate matter before administration; do not use if particulate matter present.

Administration notes:

• Inject into peripheral vein or side arm ? may be given directly into the vein or introduced into the tubing of the giving set if the patient is receiving compatible IV fluids.
• Inject slowly over 3 to 5 minutes.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration not to exceed 40 mg/mL ⁹.
• Reconstitute as for direct IV injection and dilute further by adding required dose in 50 to 100 mL of compatible IV fluid ^5,7.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer?s (Hartmann's)
• Others: Glucose and sodium chloride combinations. AVOID: Mannitol ⁷.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibilities: gentamicin, metronidazole, tobramycin, vancomycin. Other sources state further incompatibilities ^7,10,11.
• Manufacturer specifically states the following drug compatibilities: heparin (10 to 50 unit/mL), potassium chloride (10 or 40 mmol/L), theophylline (0.8 mg/mL in glucose 5%), amikacin. Other sources recommend further compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs and specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.
• Inspect visually for particulate matter before administration; do not use if particulate matter present.

Administration notes:

• Inject into peripheral vein ? may be given directly into the vein or introduced into the tubing of the giving set if the patient is receiving compatible IV fluids.
• Infuse over 30 minutes.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible IM diluent to vial.

  Reconstituted solution strength	Vial size
  	1 g
  Complete vial use ~233 mg/mL	3 mL
  Partial vial use ~200 mg/mL	3.7 mL

• Shake gently until dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection
• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Others: Lignocaine 0.5%, Lignocaine 1% (IM injection only). Not usually required because cefepime causes little or no irritation upon IM administration.

Injection solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.

Administration notes:

• Inject deep into large muscle mass (such as the upper, outer quadrant of the gluteus maximus).
• Does greater than 1 gram should not be administered intramuscularly. Consider IV administration.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity or anaphylaxis ^4,9.
• Use with caution in patients with hypersensitivity to penicillin (possibility of cross-sensitivity) ¹¹
• Consider if specimen for culture and sensitivity testing required before first dose ¹¹.
• Monitor injection site for thrombophlebitis. Change site regularly

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. DBL? Cefepime Powder for Injection [Medsafe Datasheet]. Hospira NZ Limited, 17 August 2011
2. New Zealand Formulary. Cefepime [Accessed 06April 2015]
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 22 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cefotaxime.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding the appropriate volume of compatible IV diluent to vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g
  Complete vial use	2 mL 1a	4 mL 1b
  Partial vial use ~ 200 mg/mL	2.2 mL	4.6 mL

• Shake well until dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.

Administration notes:

• Inject into peripheral vein or side arm - may be given directly into the vein preferably using butterfly or scalp vein-type needles ^5,10 or via the tubing of the giving set if the patient is receiving compatible IV fluids ^10,11.
• Inject slowly over 3 to 5 minutes ^3,4,6,10. Do not inject over less than 3 minutes as rapid injection (less than 1 minute) has been associated with potentially life-threatening arrhythmias ^5,6.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Reconstitute as for direct IV injection and dilute further by adding required dose in 40 to 100 mL of compatible IV fluid ^5,6

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer?s (Hartmann's)
• Others: Glucose and sodium chloride combinations, Dextran 40 or 70 in glucose 5% or sodium chloride 0.9%.

AVOID: Sodium bicarbonate or other alkaline solutions (pH > 7.5).

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturers specifically state the following drug incompatibilities: aminoglycosides. Other sources state further incompatibilities ^6,10.
• Some sources state some drug compatibilities ^6,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use (no preservative). If storage is required, see 'Storage' above.

Administration notes:

• Infuse into peripheral vein. Rapid infusion via central venous catheter may cause life-threatening arrhythmias ^1a.
• Infuse over 15 to 60 minutes ^1a,3,4,5,6; usually 20 to 30 minutes ^9,10.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding the appropriate amount of water for injection to the vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g
  Complete vial use	2 mL 1a	4 mL 1b

• Shake well until dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection (may be painful).
• Others: Lignocaine 0.5%, Lignocaine 1% (IM injection only).

Injection solution properties and stability:

• Prepare immediately before use (no preservative).

Administration notes:

• Inject deep into large muscle, e.g. gluteal muscle or lateral thigh ^7,11.
• AVOID injecting more than 4 mL of solution in either buttock. For doses of 2 grams or more, divide dose and administer at two injection sites ¹¹.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity or anaphylaxis.
• Caution in patients with hypersensitivity to penicillins (possibility of cross-sensitivity ¹¹).
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor liver, renal and haematological function periodically in prolonged treatment (longer than 7 days).

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. (a) Cefotaxime Sandoz [Medsafe Datasheet]. Novartis NZ Limited, 09 December 2014
   (b) DBL Cefotaxime Sodium[Medsafe Datasheet]. Hospira NZ Limited, 13 February 2014
2. New Zealand Formulary. Cefotaxime [Accessed 6 April 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014.
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 06 April 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cefoxitin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Final concentration not to exceed 100 mg/mL.
• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength	Vial size
  	1 g
  Complete vial use ~95 mg/mL	10 mL
  Part vial use ~ 100 mg/mL	9.5 mL 7

• Shake gently until all the powder is dissolved and let stand until clear.

Compatibility ? Diluents for direct IV injection:

• Water for injection
• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Others: Glucose 10%

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject into peripheral vein.
• Use butterfly or scalp vein-type needles (rather than indwelling catheters) to reduce the incidence of thrombophlebitis 5.
• Inject slowly over 3 to 5 minutes.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration not to exceed 40 mg/mL ⁴.
• Reconstitute as for direct IV injection and dilute further by adding required dose in 50 or 100 mL of compatible IV fluid ^5,9.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose 10%, Glucose and sodium chloride combinations, Mannitol 10% ⁴, Sodium bicarbonate ⁴.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer does not state any specific drug incompatibilities. However, other sources do state some incompatibilities ^7,10,11.
• Manufacturer specifically states the following drug compatibility: heparin (100 unit/mL). Other sources recommend further compatibilities ^7,10,11. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' for diluted solutions above.

Administration notes:

• Infuse into peripheral vein directly using butterfly or scalp vein-type needles (rather than indwelling catheters) to reduce the incidence of thrombophlebitis ⁵ or via tubing running compatible IV fluids.
• Infuse over 10 to 60 minutes ⁴.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Final concentration 400 mg/mL.
• Reconstitute by adding 2 mL of compatible diluent for IM injection to vial.

  Reconstituted solution strength	Vial size
  	1 g
  Complete vial use ~400 mg/mL	2 mL

• Shake gently until all the powder is dissolved and let stand until clear.

Compatibility ? Diluents for IM administration:

• Water for injection
• Others: Lignocaine 0.5%; Lignocaine 1% (IM injection only).

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject deep into a large muscle such as upper outer quadrant of gluteus ⁵.
• After needle insertion, draw back on plunger to ensure needle is not in a blood vessel ⁵.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis to cefoxitin.
• Caution in patients with hypersensitivity to penicillins (possibility of cross sensitivity) ¹¹.
• Consider if specimen for culture and sensitivity testing is required before administering the first dose ¹¹.
• Monitor injection site for signs of thrombophlebitis. Use small needles, and large veins and rotate infusion sites. ⁹
• Monitor renal, liver and haematological function periodically during prolonged therapy ⁹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Hospira Cefoxitin Sodium Powder for Injection [Medsafe Datasheet]. Hospira NZ Limited, 15 November 2011
2. New Zealand Formulary. Cefoxitin [Accessed 05 April 2015]
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 05 April 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: ceftazidime.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial (see specific procedure on next page).

  Reconstituted solution strength	Vial size
  	500 mg	1 g	2 g
  Complete vial use ~90 mg/mL	5 mL	10 mL	-
  Partial vial use ~100 mg/mL	-	8.9 mL 7	-
  Complete vial use ~170 mg/mL	-	-	10 mL
  Partial vial use ~200 mg/mL	-	-	8.2 mL 7

• Procedure for reconstitution:
  1. Introduce the syringe needle through the vial closure and inject the diluent.
  2. Withdraw the needle and shake the vial gently to give a clear solution. Carbon dioxide is released and a positive pressure develops.
  3. Invert the vial. With the syringe piston fully depressed insert the needle into the solution. Withdraw the total volume of solution into the syringe ensuring that the needle remains in the solution. Small bubbles of carbon dioxide may be ignored.

Compatibility ? Diluents for direct IV injection:

• Water for injection ⁷.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject into peripheral vein or side arm - may be given directly into the vein or introduced into the tubing of a giving set if the patient is receiving IV fluids.
• Inject slowly over 3 to 5 minutes ^5,7,9.

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Final concentration not to exceed 40 mg/mL ⁷ unless patient is fluid restricted when higher concentrations may be used ¹⁰, e.g. sodium chloride 0.9% - 63 mg/mL, glucose (dextrose) 5% - 70 mg/mL.
• Reconstitute as for direct IV injection and dilute further by adding required dose in appropriate volume of compatible IV fluid, usually 50 or 100 mL.
• Procedure for reconstitution and dilution for 1 and 2 gram vials:
  1. Introduce the syringe needle through the vial closure and inject 10 mL of diluent.
  2. Withdraw the needle and shake the vial gently to give a clear solution. Carbon dioxide is released and a positive pressure develops.
  3. Once the powder is completely dissolved, insert a needle through the vial closure to relieve the internal pressure. To preserve product sterility it is important that this performed only after the powder is completely dissolved.
  4. Transfer the reconstituted solution to compatible IV fluid.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose 10%, Glucose and sodium chloride combination, Dextran 40 or 70 in sodium chloride 0.9% or glucose 5%.

AVOID: Sodium bicarbonate.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibilities: aminoglycosides, vancomycin. Other sources state further incompatibilities ^7,10,11.
• Manufacturer specifically states the following drug compatibilities: cefuroxime, heparin (10 and 50 unit/mL), hydrocortisone sodium phosphate, metronidazole, potassium chloride (10 and 40 mmol/L). Other sources recommend further drug compatibilities ^9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse into peripheral vein directly or into tubing running compatible IV fluids.
• Infuse over 15 to 30 minutes ^{4,5,7,9,10,11}.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IM injection to vial (use same procedure as for direct IV injection but using appropriate IM diluent and volume).

  Reconstituted solution strength	Vial size
  	500 mg	1 g
  Complete vial use ~260 mg/mL	1.5 mL	3 mL

Compatibility ? Diluents for IM administration:

• Water for injection
• Others: Lignocaine 0.5%, Lignocaine 1% (IM injection only) ^4,5,7,10.

Injection solution properties and stability:

• Prepare immediately before administration. If storage required, see 'Storage' above.

Administration notes:

• Do not administer doses of more than 1 gram intramuscularly ⁷.
• Inject deep into a large muscle mass such as the upper outer quadrant of the gluteus maximus or lateral part of the thigh.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis to ceftazidime.
• Caution in patients with hypersensitivity to penicillins (possibility of cross-sensitivity ¹¹).
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Fortum [Medsafe Datasheet]. GlaxoSmithKiline NZ Limited, 26 February 2015
2. New Zealand Formulary. Ceftazidime [Accessed 06 April 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 06 April 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: ceftriaxone.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g	2 g
  Complete vial use	5 mL	10 mL	20 mL 4,5,11
  Part vial use ~100 mg/mL	4.8 mL 4,5,10,11	9.5 mL 4,5,10,11	19.2 mL 4,5,10,11

• Shake gently until all the powder is dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

AVOID: Solutions containing calcium including Lactated Ringer's (Hartmann's) and Ringer's solution.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject into peripheral vein or side arm.
• It is recommended that single doses above 1 gram should be administered by IV infusion ².
• Inject slowly over 2 to 4 minutes. One source recommends 1 to 4 minutes ⁴. Slow administration reduces risk of thrombophlebitis.

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Final concentration for IV infusion should not exceed 50 mg/mL; concentrations between 10 and 40 mg/mL are recommended 9,10 but lower concentrations may be used ¹⁰.
• Reconstitute solution as for direct IV injection and dilute further by adding required dose in at least 40 mL, usually 50 to 100 mL, of compatible IV fluid.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Others: Glucose 10%, Glucose/sodium chloride combinations, Dextran 6% in dextrose 5%; Hydroxyethyl starch 6-10%; Mannitol ¹⁰.

AVOID: Solutions containing calcium.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer recommends ceftriaxone should NOT be co-administered with calcium containing products even via different infusion lines at different sites (theoretical risk of precipitation/particulate formation). As a further caution, manufacturer recommends ceftriaxone should not be administered within 48 hours of a calcium-containing IV solution.
• Manufacturer specifically states the following drug incompatibilities: aminoglycosides, amsacrine, fluconazole, vancomycin. Other sources state further incompatibilities ^7,9,10.
• Some sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Reconstituted and diluted solutions should be prepared immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse via central or peripheral line.
• Infuse over 30 minutes; some sources recommend a minimum of 15 minutes ^5,10.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Usually 250 mg/mL, up to 350 mg/mL may be used.
• Reconstitute by adding appropriate volume of compatible diluent for IM administration to vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g	2 g
  250 mg/mL	1.8 mL 4,7,10	3.5 mL	7.2 4,10
  350 mg/mL	1.0 mL 4,10	2.1 mL 4,7,10	4.2 4,7,10

Compatibility ? Diluents for IM administration:

• Water for injection (painful without lignocaine)
• Other: Lignocaine 1% (IM injection only).

AVOID: Solutions containing calcium.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject deep into gluteal or other large muscle.
• Doses of more than 1 gram should be divided and injected at more than one site.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis to ceftriaxone.
• Caution in patients with hypersensitivity to penicillins (possibility of cross-sensitivity ¹¹).
• Consider if specimen for culture and sensitivity testing is required before administering first dose ¹¹.
• Calcium ceftriaxone can appear as a precipitate in urine, and biliary precipitation can lead to symptoms in susceptible patients.
• Monitor complete blood count during prolonged therapy, i.e. 10 days or more.
• Monitor plasma concentration of ceftriaxone when doses greater than 2 grams are used in patients with both hepatic and renal impairment ⁹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Ceftriaxone-AFT [Medsafe Datasheet]. AFT Pharmaceuticals August 2014
2. New Zealand Formulary. Ceftriaxone. [Accessed 23 March 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 18 June 2014]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer Lippincott Williams & Wilkins, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cefuroxime.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength	Vial size
  	750 mg	1.5 g
  Complete vial use	6 to 8.3 mL 1,3,5,9,10,11	15 to 16 mL 1,3,5,9,10,11
  Part vial use ~ 100 mg/mL	7 mL 12	14 mL 12

• Shake gently until all the powder is dissolved.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject into a large peripheral vein or side arm with free flowing compatible IV fluid (See below).
• Inject slowly over 3 to 5 minutes ^3,4,5,6,9.

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Dilute to 100 mg/mL or less to effect complete dissolution ⁵; usual concentration is between 1 mg/mL and 30 mg/mL ⁵.
• Reconstitute solution as for direct IV injection and dilute further by adding required dose in 50 or 100 mL of compatible IV fluid.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose 10%, Glucose and sodium chloride combinations, Ringer's.

AVOID: Sodium bicarbonate. However, if required cefuroxime sodium may be given into the tubing of a sodium bicarbonate infusion.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibility: aminoglycosides. Other sources state further incompatibilities ^10,11.
• Manufacturer specifically states the following drug compatibilities: metronidazole, hydrocortisone sodium phosphate, heparin (10 and 50 unit/mL), potassium chloride (10 and 40 mmol/L). Other sources recommend further drug compatibilities ^9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse into a peripheral vein directly or into tubing running compatible IV fluids.
• Infuse over 15 to 60 minutes ^4,5,10,11; usually over 30 minutes ^3,9.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute each 750 mg vial with 3 mL water for injection (final concentration ~ 225 mg/mL).
• Shake gently to produce an opaque suspension.

Compatibility ? Diluents for IM administration:

• Water for injection
• Other: Lignocaine 1% (IM injection only).

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject deep into a large muscle such as the gluteus or lateral aspect of the thigh ^5,11.
• After needle insertion, draw back on plunger to ensure needle is not in a blood vessel ⁵; particularly important when using lignocaine as diluent.
• Doses of more than 750 mg should be divided and injected at different injection sites, e.g. each buttock.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity/anaphylaxis to cefuroxime.
• Caution in patients with hypersensitivity to penicillins (possibility of cross-sensitivity ¹¹).
• Consider if specimen for culture and sensitivity testing is required before administering first dose ¹¹.
• Monitor injection site for signs of thrombophlebitis. Use small needles, and large veins and rotate infusion sites. ⁹
• Monitor renal, liver and haematological function periodically with prolonged therapy ⁴.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Zinacef [Medsafe Datasheet]. GlaxoSmithKline NZ Limited, 28 January 2015
2. New Zealand Formulary: Cefuroxime [Accessed 05 April 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 05 April 2015]
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014
12. Personal communication. Displacement values of cefuroxime injection when reconstituted for intravenous administration. Data on file. GlaxoSmithKline, 29 August 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cefazolin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g
  Complete vial use ~225 mg/mL	2 mL	-
  Complete vial use ~330 mg/mL	-	2.5 mL
  Partial vial use ~100 mg/mL	4.8 mL 7	9.5 mL 7

• Shake well until all powder is dissolved. Warm in hands to aid dissolution ⁷.
• Further dilute with following volume of compatible diluent for IV injection:
  • 500 mg vial: Dilute reconstituted solution in a further 5 mL ^5,11
  • 1 g vial: Dilute reconstituted solution in a further 10 mL.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare solution immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject into peripheral vein or side arm ? may be given directly into a large vein or introduced into the tubing of the giving set if the patient is receiving compatible IV fluids.
• Inspect visually for particulate matter before administration, do not use if particulate matter is present.
• Inject slowly over 3 to 5 minutes.

INTERMITTENT IV INFUSION:

Injection solution concentration and preparation:

• Reconstitute as for direct IV injection and dilute further by adding required dose to:
  • Intermittent IV infusion: 50 to 100 mL of compatible IV fluid.
  • Continuous IV infusion: usually 500 to 1,000 mL compatible IV fluid.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose 10%, Glucose and sodium chloride combinations, Ringer's, Plasma-Lyte.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibilities: aminoglycosides. Other sources state further incompatibilities ^7,10.
• Some sources state some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare solution immediately before administration. If storage is required, see 'Storage' above.

Administration notes:

• Inspect visually for particulate matter before administration, do not use if present.
• May be given directly into large vein or introduced into the tubing of the giving set if the patient is receiving compatible IV fluids.
• Intermittent IV infusion: Infuse over 10 to 15 minutes; some sources suggest 30 to 60 minutes ⁴.
• Continuous IV infusion: Infuse total daily dose over 24 hours.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IV injection to vial.

  Reconstituted solution strength	Vial size
  	500 mg	1 g
  Complete vial use ~225 mg/mL	2 mL	-
  Complete vial use ~330 mg/mL	-	2.5 mL

• Shake gently until all powder is dissolved. Warm in hands to aid dissolution ⁷.

Compatibility ? Diluents for IM administration:

• 500 mg vial:
  • Water for injection
  • Sodium chloride 0.9%
• 1 gram vial:
  • Water for injection.

Injection solution properties and stability:

• Prepare solution immediately before administration. If storage is required, see 'Storage' above.

Administration notes:

• Inspect visually for particulate matter before administration, do not use if particulate matter is present.
• Inject deep into a large muscle mass (usually minimal pain).

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity or anaphylaxis.
• Caution in patients with hypersensitivity to penicillins (risk of cross-sensitivity).
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor injection/infusion site for signs of thrombophlebitis. Change sites regularly.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Cefazolin-AFT [Medsafe Datasheet]. AFT Pharmaceutical Limited, 24 August 2011
2. New Zealand Formulary. Cefazolin [Accessed 31 March 2015]
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 31 March 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: ciprofloxacin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Use undiluted (2 mg/mL).

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer recommends ciprofloxacin should not be mixed with other drugs or infusion solutions which are chemically and physically unstable at the pH of ciprofloxacin (pH 3.5 to 4.6) and especially when combined with alkaline solutions.
• Other sources recommend some compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Contains no preservative. Discard any unused solution at the end of each infusion.

Administration notes:

• Administer via a large vein (reduces risk of venous irritation).
• Infuse over a minimum of 60 minutes (reduces risk of venous irritation).
• Where only one line exists, it is advised to temporarily discontinue the primary infusion and flush with either glucose (dextrose) 5% or sodium chloride 0.9% prior to starting ciprofloxacin infusion. Once infusion has completed, re-flush line, then recommence other infusion(s).

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Ensure adequate hydration and urinary output and avoid alkalinisation of urine to reduce the risk of ciprofloxacin crystalluria; more likely to occur in patients receiving high doses.
• Monitor renal, hepatic and haematological function periodically during prolonged therapy ⁴.
• Observe for changed bowel frequency ? risk of colitis with prolonged therapy.
• Monitor for tendon pain or inflammation ? may cause tendon rupture.
• Monitor for signs and symptoms of myasthenia gravis ? may exacerbate muscle weakness.
• Monitor injection site for thrombophlebitis ? less likely if infused over 60 minutes and in to large veins.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Aspen-Ciprofloxacin Injection [Medsafe Datasheet]. Pharmacy Retailing (NZ) Ltd, Datasheet date 24 July 2012
2. New Zealand Formulary. Ciprofloxacin [Accessed 11 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 11 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6^th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17^th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: colistimethate.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

Dose in obese patients should be calculated using ideal body weight, not actual body weight.

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding 2 mL of compatible diluent for direct IV injection (concentration = 75 mg/mL).
• Gently swirl until all the powder is dissolved (avoid frothing).

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject over 3 to 5 minutes.

INTERMITTENT OR CONTINUOUS IV INFUSION:

Infusion solution concentration and preparation:

• Reconstitute vial as for direct IV injection and further dilute by adding required dose to a sufficient amount of compatible IV fluid.
  • Intermittent IV infusion: dilute each divided dose further in 100 mL compatible IV fluid ⁷.
  • Continuous IV infusion: dilute half the daily dose in a volume of compatible IV fluid based on the patient?s fluid needs.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Other: Glucose/sodium chloride combinations.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information on drug incompatibilities or compatibilities.
• Other sources recommend some compatibilities 7,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.
• Lactated Ringer's (Hartmann's)
• Other: Glucose/sodium chloride combinations.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse:
  • Intermittent IV infusion: over 30 minutes ^4,7.
  • Continuous IV infusion: start the infusion 1 to 2 hours after the initial daily dose and infuse at a rate to deliver the dose over the next 22 to 23 hours, e.g. 5 to 6 mg/hour.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding 2 mL of compatible diluent for direct IV injection (concentration = 75 mg/mL).
• Gently swirl until all the powder is dissolved (avoid frothing).

Compatibility ? Diluents for IM administration:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject deep into a large muscle mass.
• Rotate injection site with each dose.

MONITORING/OBSERVATION/CAUTION

• Monitor for hypersensitivity/anaphylaxis.
• Colistimethate sodium is a prodrug which is metabolised to colistin the active form. The doses of the two forms are not equivalent, and some references refer to doses of the prodrug colistimethate sodium. Double check which form the text is referring to prior to drug administration.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Colistin-Link? [Medsafe Datasheet]. Link Pharmaceuticals Ltd, 30 June 2014
2. New Zealand Formulary. Colistimethate [Accessed 13 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 14 June 2014] 7
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: daptomycin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by gently adding the appropriate volume of sodium chloride 0.9% by pointing the stream toward the vial wall while gently rotating the vial to wet the powder:

  Reconstituted solution strength	Vial size
  	350 mg	500 mg
  Complete vial ~50 mg/mL	7 mL	10 mL

Compatibility ? Diluents for direct IV injection:

• Sodium chloride 0.9%.

AVOID: Glucose (dextrose)-containing diluents.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Inject slowly over 2 minutes.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• • Final concentration not to exceed 20 mg/mL ^5,10.
  • Reconstitute as for direct IV injection and dilute further by adding required dose to an appropriate volume of compatible IV fluid, usually 50 mL.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Lactated Ringer's (Hartmann's).

AVOID: Glucose (dextrose)-containing IV fluids

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states not to mix with any drugs in the same infusion solution.
• Manufacturer specifically states the following drug compatibilities when administered via a Y-site from separate infusion bags: aztreonam, ceftazidime, ceftriaxone, gentamicin, fluconazole, dopamine, heparin, and lidocaine.
• Other sources recommend additional compatibilities via the Y-site ^7,9,11. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.

Administration notes:

• Infuse over 30 minutes.

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before the first dose ¹¹.
• Monitor for muscle pain or weakness, particularly of the distal extremities.
• Monitor creatine phosphokinase weekly or more frequently if current or prior statin therapy ⁴.
• Monitor for signs and symptoms of eosinophilic pneumonia ^4,11, e.g. cough, worsening fever, shortness of breath, difficulty breathing ^5,11.
• Observe for changed bowel frequency ? risk of colitis ¹¹.
• Monitor complete blood count, renal and hepatic function weekly or more frequently if indicated ¹¹.
• Consider repeat cultures in patients relapsing or responding poorly ⁹.
• Monitor IV site carefully and rotate as indicated.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Cubicin [Medsafe Datasheet]. Novartis New Zealand Limited, 10 March 2015
2. New Zealand Formulary. Daptomycin [Accessed 17 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 17 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to Manufacturer?s Package Insert.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

Parenteral doxycycline should be used only when oral therapy is not feasible.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration is between 0.1 mg/mL to 1 mg/mL.
• Reconstitute powder by adding 10 mL water for injection (or any compatible IV fluids listed below) to vial (reconstituted solution concentration ~10 mg/mL):

  Reconstituted solution strength	Vial size
  	100 mg
  Complete vial use ~10 mg/mL	10 mL

• Shake well until all the powder is dissolved.
• Dilute further with 100 mL to 1,000 mL of compatible IV fluid.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%.
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's).
• Others: Glucose 5% in lactated Ringer's (Hartmann's), Plasma-Lyte, Ringer's.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer makes no recommendations about drug compatibilities or incompatibilities.
• Doxycycline solutions are acidic and therefore incompatibility with alkaline solutions or drugs unstable at low pH should be reasonably expected ⁶.
• Other sources recommend some drug compatibilities ^9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter before administration, do not use if present.

Administration notes:

• Infuse over 1 to 4 hours (duration depends on dose and concentration), e.g.:
  • 100 mg at 1 mg/mL concentration over 2 hours
  • 100 mg at 0.5 mg/mL concentration over 1 hour.
• Avoid rapid administration.
• During infusion protect solution from direct sunlight.
• Avoid extravasation ⁴.

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis.
• Consider of specimen for culture and sensitivity is required before first dose ^4,11.
• Monitor injection site for thrombophlebitis.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Doxycycline Hyclate Injection [Manufacturer Datasheet]. Pfizer Inc., November 2012
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 18 July 2015]
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: ertapenem.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration 20 mg/mL or less ⁹.
• Reconstitute the powder by adding 10 mL of compatible IV diluent intended for IV use to vial.
• Shake well to dissolve.
• Dilute further by immediately transferring reconstituted solution to an appropriate volume of compatible IV fluid for infusion, usually 50 mL - concentration ~ 16.7 mg/mL.

Compatibility ? Diluent for reconstituting powder intended for IV use after further dilution:

• Sodium chloride 0.9%
• Water for injection (may be bacteriostatic).

AVOID: Glucose-containing solutions, lidocaine (for IM use only).

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%.

AVOID: Glucose-containing solutions, Lactated Ringer's (Hartmann's) ⁷, mannitol ¹⁰, Ringer's ¹⁰. sodium bicarbonate ¹⁰.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information on drug incompatibilities or compatibilities.
• Other sources recommend some drug compatibilities 7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter or discolouration; do not use if present.

Administration notes:

• Central or peripheral line.
• Infuse over 30 minutes ^4,7,9,11.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute the powder by adding 3.2 mL of compatible diluent for IM injection.
• Shake thoroughly until all the powder is dissolved.

Compatibility ? Diluents for IM administration:

• Lidocaine 1% (IM injection only).

AVOID: Glucose 5%, water for injection (may be painful).

Injection solution properties and stability:

• Prepare immediately before use and administer within 1 hour.
• Visually inspect for particulate matter or discolouration; do not use if present.

Administration notes:

• Check the patient is not allergic to lidocaine.
• Do injection into a blood vessel (lidocaine contraindicated).
• Inject deep into large muscle mass, e.g. gluteal muscle or lateral part of the thigh.

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis ? more likely to occur in patients with a history of sensitivity to multiple allergens. Consider cross sensitivity with other beta lactams, penicillins or cephalosporins.
• Monitor injection site; rotate as indicated.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor for signs and symptoms of CNS reactions (focal tremors, myoclonus, seizures) ⁹.
• Monitor renal, hepatic and haematopoietic system in prolonged therapy.
• Observe for changed bowel frequency ? risk of colitis.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Invanz [Medsafe Datasheet]. Merck Sharp and Dohme (NZ) Limited, July 2015
2. New Zealand Formulary. Ertapenem [Accessed 21 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 21 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: erythromycin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT OR CONTINUOUS IV INFUSION:

Infusion solution concentration and preparation:

• Usual concentration:
  • by intermittent IV infusion:
    • 1 to 5 mg/mL via peripheral line.
    • minimum dilution via central line: 10 mg/mL ⁸; however, there are anecdotal reports of 1 gram in 20 mL (50 mg/mL reconstituted solution) or 1 gram in 40 mL (25 mg/mL) being used via a central line in fluid-restricted patients ⁸.
  • by continuous IV infusion:
    • 1 mg/mL via peripheral line or central line.
• Reconstitute by adding 20 mL water for injection to the vial; concentration 50 mg/mL.
• Shake well ensuring all the powder is dissolved.
• Withdraw dose (there is an overage to ensure that the full stated dose can be withdrawn).
• Dilute further by adding dose to appropriate volume of compatible IV fluid, e.g:

  Diluted solution strength	500 mg	750 mg	1 g
  Complete or partial vial use ~5 mg/mL	100 mL	-	200 mL
  Complete or partial vial use ~3 mg/mL	-	250 mL	-
  Complete or partial vial use ~1 mg/mL	500 mL	750 mL	1,000 mL

• Some IV fluids require buffering with 0.5 mL sodium bicarbonate 8.4% per 100 mL diluted solution (see 'Compatibility ? IV fluids appropriate to dilute IV solution' below).

Compatibility ? Diluent for reconstituting powder intended for IV use after further dilution:

• Water for injection

AVOID: Any other diluent as may cause precipitation.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5% (buffer - 0.5 mL sodium bicarbonate 8.4% per 100 mL solution)
• Lactated Ringer's (Hartmann's)
• Others: Glucose 5% in sodium chloride 0.9% (buffer), glucose 5% in Lactated Ringer's (buffer).

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer provides no information regarding drug incompatibilities or compatibilities.
• Some sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter or discolouration, do not use if present.
• Use within 8 hours of preparation.

Administration notes:

• Peripheral or central line for concentrations up to 5 mg/mL.
• Must use central line for concentrations greater than 5 mg/mL.
• Infuse:
  • by intermittent IV infusion: over 60 minutes or more; consider a longer infusion time in patients with risk factors for or previous evidence of arrhythmias (QT prolongation).
  • by continuous IV infusion: total daily dose infused over 24 hours.
    Note: infusion solution must be used within 8 hours of preparation at room temperature so daily dose needs to be divided and freshly made up every 6 to 8 hours.

MONITORING/OBSERVATION/CAUTION

• Do not administer too rapidly ? risk of QT prolongation and hypotension and development of ventricular arrhythmias (may be fatal).
• Monitor for signs and symptoms of hypersensitivity/anaphylaxis.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor injection site for redness and inflammation and rotate as indicated ? very irritant. If phlebitis/pain occurs, consider slowing infusion rate, diluting solution further or consider administering via larger available vein or central line ^4,7.
• Observe for changed bowel frequency ? risk of colitis.
• Monitor hepatic function periodically during prolonged therapy ¹¹.
• Switch to oral therapy as soon as possible.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Erythrocin IV [Medsafe Datasheet]. AFT Pharmaceuticals Limited, April 2015
2. New Zealand Formulary. Erythromycin [Accessed 24 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 24 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.2 May 2013). United Kingdom Clinical Pharmacy Association; 2012
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: flucloxacillin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible IV diluent to vial.

  Reconstituted solution strength	Vial size
  	250 mg	500 mg	1 g
  Complete vial use	10 mL	10 mL	15 to 20 mL
  Part vial use ~ 25 mg/mL	9.8 mL	-	-
  Part vial use ~ 50 mg/mL	4.8 mL	9.6 mL	19.2 mL
  Part vial use ~ 100 mg/mL	-	4.6 mL	9.2 mL
  Part vial use ~ 200 mg/mL	-	-	4.2 mL

• Shake until all the powder is dissolved.
• Draw up appropriate dose and dilute further to total volume of 10 to 20 mL if required.

Compatibility ? Diluents for direct IV injection:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' section above.
• Visually inspect for particulate matter or discolouration, do not use if present.

Administration notes:

• Inject slowly over 3 to 4 minutes.
• May be injected via a drip tube over a period of 3 to 4 minutes.
• Phlebitis may occur at injection site ⁷.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Reconstitute as for direct IV injection with water for injection.
• Dilute further by adding required dose to 100 mL of compatible IV fluid ⁷.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringers (Hartmann's)
• Other: Glucose and sodium chloride combinations.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer states not to mix with blood products or proteinaceous fluids.
• Manufacturer specifically states incompatibility with aminoglycosides and other sources state further incompatibilities ^7,10.
• One source recommends some drug compatibilities ¹⁰. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' section above.
• Visually inspect for particulate matter or discolouration, do not use if present.

Administration notes:

• Infuse over 30 to 60 minutes ⁷.
• Phlebitis may occur at injection site ⁷.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent for IM administration.

  Reconstituted solution strength	Vial size
  	250 mg	500 mg	1 g
  Complete vial use	1.5 mL	2 mL	2.5 mL
  Part vial use ~ 100 mg/mL	2.3 mL	-	-
  Part vial use ~ 125 mg/mL	1.8 mL	3.6 mL	-
  Part vial use ~ 200 mg/mL	-	2.1 mL	-
  Part vial use ~ 250 mg/mL	-	1.6 mL	-
  Part vial use ~ 500 mg/mL	-	-	1.2 mL

• Shake until all the powder is dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' section above.
• Visually inspect for particulate matter or discolouration, do not use if present.

Administration notes:

• Inject deep into a large muscle.
• Pain may occur at injection site ⁷.

INTRA-ARTICULAR INJECTION:

Injection solution concentration and preparation:

• Reconstitute by adding appropriate volume of compatible diluent.

  Reconstituted solution strength	Vial size
  	250 mg	500 mg
  Complete vial use	Up to 5 mL	Up to 5 mL

• Shake until all powder is dissolved.

Compatibility ? Diluents for IM administration:

• Water for injection
• Other: Lidocaine hydrochloride 0.5%.

Injection solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' section above.
• Visually inspect for particulate matter or discolouration, do not use if present.

Administration notes:

• Inject directly into joint space.

MONITORING/OBSERVATION/CAUTION

• Monitor for early signs and symptoms of hypersensitivity or anaphylaxis.
• Monitor injection/infusion site and rotate as indicated.
• Monitor renal and hepatic function periodically, particularly during prolonged therapy ? risk of flucloxacillin-induced jaundice and proteinuria.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Flucloxin [Medsafe Datasheet]. Douglas Pharmaceuticals Ltd, 18 December 2014
2. New Zealand Formulary. Flucloxacillin [Accessed 16 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3^rd ed. Oxford, New York: Radcliffe Publishing; 2009
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 27 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: fluconazole.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Use premixed infusion solution (2 mg/mL). Further dilution is not recommended.

Compatibility ? IV fluids appropriate to administer concomitantly via Y-site:

Manufacturer recommends that fluconazole may be administered through an existing IV line running one of the following IV fluids (otherwise administer separately):

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann's)
• Others: Glucose 20%, Ringer's, sodium bicarbonate 4.2%.

Compatibility ? Drugs administered via Y-site:

• Manufacturer recommends not mixing with any other medication prior to infusion.
• Other sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Visually inspect for particulate matter or discolouration, do not use if present.
• Do not use if the seal is not intact.
• Discard any solution remaining 24 hours after opening.

Administration notes:

• Peripheral or central line.
• Infuse at a rate not exceeding 200 mg/hour (100 mL/hour for premixed solution).

MONITORING/OBSERVATION/CAUTION

• Take sodium content and the total volume of fluid administered into consideration for patients who are sodium-restricted and/or fluid-restricted.
• Consider if specimen for culture and sensitivity is required before the first dose ⁹.
• Monitor for signs and symptoms of hypersensitivity or anaphylaxis ⁹.
• Obtain baseline liver function tests and monitor regularly throughout treatment ? serious hepatotoxicity may occur. If clinical signs and symptoms consistent with liver toxicity develop, discontinue therapy.
• Observe for skin reactions - rarely exfoliative cutaneous reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, have occurred during treatment ⁹.
• Consider ECG monitoring in patients at risk of QT prolongation ⁹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Fluconazole-Claris [Medsafe Datasheet]. AFT Pharmaceuticals Ltd, 05 May 2010
2. New Zealand Formulary. Fluconazole [Accessed 26 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 26 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: ganciclovir.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Prepare using precautions for handling cytotoxic medications.
• Final concentration should not exceed 10 mg/mL, particularly relevant if infusing via a peripheral vein. Using a higher concentration is not recommended ^8,10.
• Reconstitute powder by adding 10 mL water for injection (concentration = 50 mg/mL). Do not use bacteriostatic water for injection containing parabens (hydroxybenzoates) for reconstitution as precipitation may result.
• Shake vial to dissolve powder.
• Dilute the required dose further in 50 to 250 mL (typically 100 mL) of compatible IV fluid ^5,10,11.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%
• Lactated Ringer's (Hartmann?s)
• Others: Ringer's.

AVOID: All other IV fluids.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer recommends not mixing with any other medications.
• Other sources recommend some compatibilities 7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter or discolouration; do not use if present.
• Discard any unused reconstituted or diluted solution.

Administration notes:

• Central line, or peripheral line using small needles and large veins with adequate blood flow to reduce risk of irritation and phlebitis (high pH) ^7,9.
• Administer via an infusion pump ^9,11.
• Flush line with sodium chloride 0.9% before and after administration ^4,9.
• Infuse each dose over 1 hour.

MONITORING/OBSERVATION/CAUTION

• Avoid rapid infusion ? increases risk of toxicity ⁴.
• Avoid extravasation ? confirm patency of vein before administration ⁹.
• Monitor for injection site reaction (irritation and phlebitis ? very irritant ⁷.
• Maintain adequate hydration and urine flow before and during infusion ⁹.
• Monitor complete blood count, serum electrolytes and renal function twice weekly during induction and weekly thereafter ⁶.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Cymevene® [Medsafe Datasheet]. Roche Products (New Zealand) Limited, 31 May 2011
2. New Zealand Formulary. Ganciclovir [Accessed 27 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 27 July 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.2 May 2013). United Kingdom Clinical Pharmacy Association; 2012
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: gentamicin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

DIRECT IV INJECTION:

Injection solution concentration and preparation:

• Use undiluted ⁸ or dilute with 20 mL ⁷ compatible IV diluent.

Compatibility ? Diluents for direct IV injection:

• Sodium chloride 0.9% ⁷.

Injection solution properties and stability:

• Draw up (or if diluted prepare) solution immediately before use.
• Use diluted solutions within 24 hours after preparation.

Administration notes:

• Inject over 3 to 5 minutes ^2,6,7.
• Flush line after infusion to ensure full dose is delivered.

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Prepare infusion solution by adding appropriate dose to 50 to 200 mL of compatible IV fluid ^1a,5,11; recommended concentration should not to exceed 1mg/mL.
• The final concentration of diluted solution for infusion is dose-related, e.g. higher doses and once-daily regimens may necessitate higher concentrations ? consult local protocols.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9%
• Glucose (dextrose) 5%.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Gentamicin must not be mixed physically with other medications in the same infusion solution or infused simultaneously through the same tubing.
• Gentamicin is inactivated by solutions containing penicillins; it is recommended that gentamicin and penicillin doses are administered separately and at different sites to avoid mixing these medications in administration lines.
• Other sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare solution immediately prior to infusion (no preservative). If storage is required, see 'Storage' above.
• Discard any unused portion.

Administration notes:

• Peripheral vein or central line.
• Infuse over 30 minutes to 2 hours. Consult local protocols.
• Flush line after infusion to ensure full dose is delivered.

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Use undiluted solution. Use stronger solution to minimise volume to be injected.

Injection solution properties and stability:

• Draw up immediately prior to use.

Administration notes:

• Inject directly into large muscle.
• Avoid administration into blood vessel.

MONITORING/OBSERVATION/CAUTION

• Monitor for hypersensitivity/anaphylaxis to drug and any excipients.
• Do not use in patients with previous hypersensitivity or serious nephrotoxicity and/or ototoxic reactions to any aminoglycoside.
• Avoid concomitant use with other antibiotics or potent diuretics that may enhance neurotoxicity and/or nephrotoxicity.
• Use with caution in patients with muscular disorders, e.g. myasthenia gravis or Parkinson's disease (may aggravate muscle weakness) and patients receiving neuromuscular blockers.
• Prior to therapy, assess renal function (where possible) and obtain a specimen for culture and sensitivity ¹¹.
• Monitor IV site regularly and rotate injection site to reduce risk of local irritation and pain.
• Maintain adequate hydration throughout therapy.
• Notify prescriber if patient develops tinnitus, vertigo or hearing impairment. Monitor auditory and vestibular function regularly (e.g. weekly), particularly in patients undergoing prolonged or repeated therapy ^9,11.
• Monitor renal function and urinary output daily ⁹.

Therapeutic Drug Monitoring

• Gentamicin plasma concentrations should be monitored periodically to optimise efficacy and reduce toxicity, particularly in patients with renal impairment.
• Consult local hospital guidelines for frequency of monitoring and times post dose to draw levels. These will vary according to dosing interval and renal status:
  • peak levels draw specimen usually 30 minutes after the completion of IV infusion or 15 to 30 minutes after an IV injection or 1 hour following intramuscular injection
  • mid-dosing levels (as per some hospital guidelines) take a level 6 to 24 hours post dose depending on patient?s renal function and dosing interval
  • trough levels draw specimen as a close as practicable prior to the next dose, e.g. within 30 minutes. It is often not necessary or practicable to have the level back before the next dose is administered, however, the level may be used to adjust subsequent doses.
• Draw approximately 5mL of venous blood from a peripheral site (avoids antibiotic contamination).

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. (a) Gentamicin Injection [Medsafe Datasheet]. Pfizer New Zealand Ltd, 04 July 2005
   (b) DBL™ Gentamicin Injection BP [Medsafe Datasheet]. Hospira NZ Limited, 02 May 2012
2. New Zealand Formulary. Gentamicin [Accessed 15 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 15 June 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
8. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.4 13 Feb 2014). United Kingdom Clinical Pharmacy Association; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
11. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: cilastatin + imipenem.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation (concentration expressed as quantity of imipenem):

• Final concentration usually 5 mg/mL or less (preferred) ¹⁰.
  Other sources recommend as high as 10 mg/mL via a central line for fluid-restricted patients ^3,8.
  

  Reconstituted solution strength	Vial size
  	500 mg imipenem
  Complete vial use	10 mL
  Partial vial use ~50 mg/mL	9.2 mL 7

• Reconstitute the powder by adding appropriate volume of diluent from 100 mL bag (or 50 mL in fluid-restricted patients; up to 250 mL for a 1 gram dose) of compatible IV fluid, to vial.
• Shake well to disperse the powder evenly in the solution.
• Dilute further by immediately drawing up dose from reconstituted suspension and inject back into the infusion fluid or adding to an appropriate volume of compatible IV fluid.
• If using the whole vial, to ensure complete transfer of the contents from the vial to the infusion solution, repeat by adding 10 mL from the 100 mL infusion bag containing the imipenem+cilastatin to the vial and transferring back to the infusion bag again. Repeat this process until the vial is empty.
• Shake the bag well until the final solution is clear.

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9% (preferred).
• In exceptional circumstances if sodium chloride is contraindicated and diluted infusion solution can be used immediately, the following IV fluids may be considered:
  • Glucose (dextrose) 5% ^7,8,10.
  • Others: Glucose 10% 7,10, mannitol 2.5%, 5% and 10% 7, sodium chloride/glucose combinations ^7,10.

AVOID: Lactated Ringer?s (Hartmann?s), any solution containing lactate, mannitol 20% ⁷.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer states not to mix with any other antibiotics.
• Other sources recommend some drug compatibilities and incompatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate matter and discolouration (brown colour 5); do not use if present.

Administration notes:

• Central or peripheral line for 5 mg/mL; central line only for 10 mg/mL ³.
• Administer using small needles and large veins.⁹
• Duration of infusion depends on dose:
  • for doses up to 500 mg imipenem, infuse over 20 to 30 minutes.
  • for doses greater than 500 mg imipenem, infuse over 40 to 60 minutes.
• Reduce the infusion rate in patients who develop nausea, vomiting, hypotension, or sweating during the infusion ⁹.

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis ? more likely to occur in patients with a history of sensitivity to multiple allergens ⁹. Consider cross sensitivity with other beta lactams, penicillins or cephalosporins.
• If patient develops nausea or vomiting during the infusion, slow the infusion rate ^7,9.
• Monitor injection site ? use small needles in large veins (risk of thrombophlebitis, pain, inflammation), and rotate as necessary ⁹.
• Consider if specimen for culture and sensitivity testing is required before first dose ¹¹.
• Monitor for signs and symptoms of CNS reactions (focal tremors, myoclonus, seizures) ⁹.
• Monitor renal, hepatic and haematologic system in prolonged therapy.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Imipenem+Cilastatin RBX [Medsafe Datasheet]. Douglas Pharmaceuticals Ltd, 21 January 2015
2. New Zealand Formulary. Cilastatin + imipenem [Accessed 21 July 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
7. Critical Care Group. Minimum Infusion Volumes: for critically ill patients. 4th ed. (v4.4 13 Feb 2014). United Kingdom Clinical Pharmacy Association; 2014
8. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
9. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
10. Lippincott. Nursing 2015 Drug Handbook. 35th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: lincomycin.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Final concentration not to exceed 10 mg/mL ? risk of severe cardiopulmonary reactions especially hypotension at higher concentrations.
• Dilute by adding required dose to an appropriate volume of compatible IV fluid, not less than 100 mL, e.g:

  Volume lincomycin (dose) stock solution	2 mL (600 mg)	3.3 mL (1 g)	6.7 mL (2 g)	10 mL (3 g)	13.3 mL (4 g)
  Add to volume of infusion fluid	100 mL	100 mL	200 mL	300 mL	400 mL
  Total volume to be infused	102 mL	103.3 mL	206.7 mL	310 mL	413.3 ml
  Infusion solution concentration	~10 mg/mL	~10 mg/mL	~10 mg/mL	~10 mg/mL	~10 mg/mL

Compatibility ? IV fluids appropriate to dilute IV infusion:

• Sodium chloride 0.9% ^7,10
• Glucose (dextrose) 5%
• Lactated Ringers (Hartmann's)
• Others: Glucose 10% ^7,10, glucose/sodium chloride combinations, Ringer's ^7,10.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibilities: kanamycin, phenytoin.
• Other sources recommend some drug compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• Prepare immediately before use. If storage is required, see 'Storage' above.
• Visually inspect for particulate or discolouration matter, do not use it present.

Administration notes:

• Ensure patient is lying down during infusion to avoid hypotension ⁹.
• Infuse slowly at a rate not exceeding 1 g/hour - risk of cardiopulmonary reactions especially hypotension with rapid administration ⁹.

  Dose	600 mg	1 g	2 g	3 g	4 g
  Duration of infusion	1 hour	1 hour	2 hours	3 hours	4 hours

INTRAMUSCULAR INJECTION:

Injection solution concentration and preparation:

• Use undiluted (300 mg/mL).

Injection solution properties and stability:

• Prepare immediately before use.
• Discard any unused solution immediately.

Administration notes:

• Inject deep into a large muscle mass.
• Monitor for local irritation, pain induration and sterile abscess at injection site.

MONITORING/OBSERVATION/CAUTION

• Monitor for signs and symptoms of hypersensitivity/anaphylaxis.
• Monitor liver, renal and haematological function during prolonged therapy.
• Observe for changed bowel frequency ? risk of colitis with prolonged therapy and even several weeks after stopping therapy ⁷.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Lincocin® [Medsafe Datasheet]. Pfizer New Zealand Limited, 20 February 2015
2. New Zealand Formulary. Lincomycin [Accessed 19 August 2015]
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 19 August 2015]
7. Burridge N, Collard N, Symons K, eds. Australian Injectable Drugs Handbook. 6th ed. (revised April 2014). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2014
9. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
10. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: linezolid.

DOSAGE AND ADMINISTRATION

Adults ? usual dose

INTERMITTENT IV INFUSION:

Infusion solution concentration and preparation:

• Use undiluted.

Compatibility ? Drugs in the same infusion solution or Y-site:

• Manufacturer specifically states the following drug incompatibilities: amphotericin B, chlorpromazine hydrochloride, diazepam, pentamidine isethionate, erythromycin lactobionate, phenytoin sodium and sulphamethoxazole/trimethoprim. Additionally, it is chemically incompatible with ceftriaxone sodium.
• Manufacturer advises not to introduce medications into premixed infusion solution and not to use in series connections.
• When administering other drugs via the same administration set flush line well with compatible IV solution (sodium chloride 0.9%, glucose (dextrose) 5%, Lactated Ringer?s (Hartmann?s) and glucose/sodium chloride combinations) before and after delivery ¹¹.
• Other sources recommend some compatibilities ^7,9,10. Consult a pharmacist for information about individual drugs or specific conditions that may apply.

Infusion solution properties and stability:

• For single use only. Discard any unused solution (no preservative).
• Inspect visually for particulate matter before administration; do not use if present.
• The yellow colour of the infusion solution may intensify over time without affecting potency ⁴.
• Solution is isotonic.

Administration notes:

• Infuse over 30 to 120 minutes ? rate ranging from 5 to 20 mg/minute (300 to 1,200 mg/hour).

MONITORING/OBSERVATION/CAUTION

• Monitor for hypersensitivity/anaphylaxis.
• Monitor haematological function weekly during prolonged therapy, more than 2 weeks ⁴. May cause thrombocytopenia in at risk patients ¹¹. May cause myelosuppression ¹¹.
• Monitor patients taking serotonergic drugs closely ^3,11.
• Monitor for lactic acidosis ? nausea and vomiting may be a symptom ¹¹.
• Observe for changed bowel habit ? risk of colitis ¹¹.

REFERENCES

Many thanks go to the New Zealand Hospital Pharmacists Association for permission to use this content.

1. Zyvox® [Medsafe Datasheet]. Pfizer New Zealand Pty Ltd, 30 August 2013
2. New Zealand Formulary. Linezolid [Accessed 14 June 2015]
3. Ashley C, Currie A, eds. Renal Drug Handbook. 3rd ed. Oxford, New York: Radcliffe Publishing; 2009
4. Lexi-Comp Drug Information Handbook. 23rd ed. Hudson, OH: Lexi-Comp; 2014
5. AHFS Drug Information. 2014 ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014
6. Martindale: The Complete Drug Reference. [online] London: Pharmaceutical Press. [Accessed via Micromedex 2.0 http://www.micromedexsolutions.com/micromedex2/librarian/ 23 August 2014]
7. Burridge N, Deidun D, eds. Australian Injectable Drugs Handbook. 5th ed. (revised July 2012). Collingwood, VIC: Society of Hospital Pharmacists of Australia; 2012
8. Gahart BL, Nazareno AR. 2014 Intravenous Medications: A Handbook for Nurses and Health Professionals. 30th ed. St. Louis, MO: Elsevier Mosby; 2014
9. Trissel LA. Handbook on Injectable Drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013
10. Lippincott. Nursing 2014 Drug Handbook. 34th ed. Wolters Kluwer, 2014

PREPARATIONS:

BEFORE ADMINISTERING CHECK:

Indications, Contraindications, Cautions, Interactions, Hepatic impairment, Renal impairment, Pregnancy, Breast-feeding, Adverse effects by referring to NZ Formulary: meropenem.

DOSAGE AND ADMINISTRATION

Adults ? usual dose