The 2022 International Society for Peritoneal Dialysis (ISPD) guideline provides recommendations on prevention and treatment of peritonitis. It was emphasized that the stability and compatibility of antibiotics in peritoneal dialysis (PD), as described in a 2022 review article, is one of the factors influencing treatment success. The panel states that cefepime remains stable for 14 days in dextrose-based PD solutions when refrigerated, while vancomycin is stable for 28 days at room temperature, though higher ambient temperatures reduce its stability. Additionally, vancomycin’s stability in icodextrin-based PD solutions has been confirmed for 14 days at both 4°C and 25°C. [1-5] According to a 2022 review article on stability and compatibility of antibiotics in PD solutions, cefepime is less commonly used for PD-related peritonitis compared to other cephalosporins, and stability data for intraperitoneal (IP) administration is limited. Cefepime 312.5 mg in a 1.25 L bicarbonate compa...

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The recommendation for a 30 mL/kg crystalloid fluid bolus in a septic patient was established by the Surviving Sepsis Campaign (SSC), with the current guidelines published in 2018 still recommending the bolus regimen (strong recommendation, low quality of evidence). Since its publication, reviews and commentaries from real world settings note the minimal supporting clinical data and reliance on expert opinion for this recommendation. These reviews suggest that the 30 mL/kg fluid challenge can needlessly expose patients to large volumes of fluid, and could actually be harmful by overloading organ function and paradoxically worsening shock. Other guidelines like American College of Emergency Physicians (ACEP) recommend individualizing fluid resuscitation needs for each patient. [1-3] A 2020 review discussing the lack of supporting evidence for fluid resuscitation in septic shock recommends a flat initial bolus of 500 mL of balanced crystalloid solutions, followed by monitoring of p...

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The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) developed the 2022 practice parameter update on drug allergies, which addresses the topic of beta-lactam cross-reactivity. It was highlighted that guidance on administering carbapenems to patients with penicillin allergy has changed since the previous drug allergy practice parameter update. Though not specific to ampicillin, the panel suggests that in patients with a history of penicillin or cephalosporin allergy, carbapenems may be administered without testing or additional precautions, even in cases where the previous reaction was anaphylactic (conditional recommendation, moderate certainty of evidence). [1] The reported incidence of carbapenem allergy ranges from 0.3% to 3.7%. Clinical cross-reactivity between carbapenems and other beta-lactams is low, with multiple review articles reporting a cross-sensitivity risk of less than 1% between penicil...

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A 2018 systematic review evaluated the efficacy of icatibant, ecallantide, and tranexamic acid (TA) for angiotensin-converting enzyme inhibitor (ACEi) induced and idiopathic angioedema (non-hereditary AE). This systematic review included 61 studies with 38 describing treatment in the acute setting, although the majority of evidence was case reports. There were no direct comparisons between icatibant, ecallantide, or TA. For ACEi-induced AE, two randomized controlled studies of ecallantide do not suggest a significant benefit based on response rate versus placebo (10%-16% response rate). Icatibant may have similar efficacy to C1NH and fresh frozen plasma (FFP) with an average response time of less than 2 hours, but the majority of included studies were not controlled and of lower quality. Data for TA in ACEi-induced AE was not available. [1] For idiopathic AE, a single study on TA use observed a 54% response rate (13 to 24 patients). Data for icatibant and ecallantide are limited ...

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A 2015 review article discusses the use of intravenous (IV) medications in the intramuscular (IM) or subcutaneous (SQ) route. Many IV medications are not intended for administration via the IM or SQ routes due to safety concerns. IV medications are formulated for rapid absorption and effect when administered intravenously. If given via other routes, the medication may not be adequately or rapidly absorbed, resulting in suboptimal effect or even failure of the treatment. In some cases, the local vasoconstrictive or other adverse effects of the medication at the injection site could cause tissue damage if not diluted or administered properly via IM or SQ routes. However, for some IV medications, literature evidence has shown the IM or SQ routes can be options with comparable efficacy and safety when administered carefully following proper preparation guidelines (see Table 1). Medications intended for IV use but considered for IM or SQ administration should be carefully diluted accordi...

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