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Discussion

IV antibiotic administration

Question:

When initiating sepsis protocols, do you all start all IV antibiotics at once?

This has never been a practice of mine and I don’t consider this best practice. I’ve always been taught for first time administration to give antibiotics alone so that if there is a reaction you can identify the source. I had a nurse start all antibiotics at once and her rationale was that she didn’t want the patient to become “more septic” while waiting to get the additional treatment. That made no sense to me as sepsis protocols say to have antibiotics started in a timely manner, but you still have to consider patient safety. 

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    I would keep in mind that the rationale behind starting all indicated antibiotics immediately is that it is also a patient safety issue.  Although neither deeply held belief; that 'every hour counts' when it comes to starting antibiotics, or that you shouldn't give multiple antibiotics at once, is particularly well supported.

    I would agree there is some benefit of at least staggering the start of various antibiotics being administered.  The reactions we're most concerned about typically happen within the first 15 minutes of an IV dose of antibiotic.  Other reactions might occur hours after a dose is given, in which case giving them separately doesn't really help narrow down the culprit antibiotic.  And really it's the first dose where a severe allergic reaction is the most likely, it's the second.

    Well designed studies into the timing of antibiotics (how quickly they're given) don't really support many of the claims out there that delaying antibiotics by an hour for instance results in a difference in outcomes.  And just in general we really shouldn't be so quick to throw multiple antibiotics at every patient who "screens positive" in sepsis screening, that's more than a bit reckless.  

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    If antiobiotics are compatible (for example Flagyl with a cephalosporine) then we give them together. If antibiotics are not compatible we stagger them. I agree with the "get the antibiotics started as soon as possible" school of thought.

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    Our policy is to get all ordered IV antibiotics in within an hour. We start more IV sites, or start antibiotics before blood cultures are drawn if necessary.

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