A 2018 review discussing the administration of antibiotics via intravenous (IV) push suggests that IV push administration can provide clinical and practical advantages over longer IV infusions in multiple clinical scenarios. In such settings, conversion to IV push administration may provide a practical solution. Intravenous push administration allows for the administration of an antibiotic in a minimal fluid volume, which can be particularly useful in patients who are fluid-restricted, such as patients with acute volume overload. The faster administration time may also provide advantages in the emergency department (ED), making it so the time-to-first-dose can be minimized. Additionally, in the setting of drug or fluid shortages, IV push administration may help to conserve supplies. [1]
With the many benefits of administering antibiotics via IV push, one of the primary advantages is that, in cases where immediate administration is required for medication stability or for clinical necessity, preparation and dilution of the medication can occur in patient care areas. Additionally, for agents that are concentration-dependent, IV push administration allows for maximizing the area under the curve (AUC) per unit of time in relation to the bacterial minimum inhibitory concentration (MIC), increasing the rapidity of bacterial killing and the likelihood of a good clinical outcome. It should be noted, however, that several studies have found extended and continuous infusion strategies to be associated with improved clinical cure and survival, particularly in severely ill patients, compared with shorter infusion durations. Thus, current data do not support the substitution of IV push for extended or continuous infusion schemes in patients who are critically ill, immunocompromised, or infected with organisms with MICs at or above the clinical breakpoint for susceptibility. In general, precautions should be taken to ensure safe IV push administration, including clear labeling and staff education. Additionally, pharmacodynamic changes due to IV push administration should be considered, such as effects on time above MIC when administering antibiotics via IV push that are normally administered via extended or continuous infusions. [1]
Ceftriaxone IV push administration has been studied in different settings, including in hospitalized patients, in the ED, and with outpatient parenteral antibiotic therapy; reports of concerns with IV push administration were minimal in the literature. Rapid ceftriaxone administration (2 grams over 5 minutes) was reported to be associated with palpitation, tachycardia, restlessness, shivering, and diaphoresis in an adult patient. In the pediatric population, ceftriaxone has been associated with increased biliary pseudolithiasis (ceftriaxone given over 3 to 5 minutes) and with the formation of a calcium-ceftriaxone precipitate in neonates receiving concurrent calcium-containing solutions, which led to adverse cardiopulmonary events (ceftriaxone given over 2 to 4 minutes). Description of how IV push administration of ceftriaxone may affect the efficacy of the drug was not discussed. [1]
Another commentary published in 2021 states that time to antibiotic administration is an important parameter for ED patients, particularly in the case of sepsis and septic shock. Notably, two large retrospective cohort studies found that shorter time to antibiotics was associated with a reduction in mortality in patients with sepsis and septic shock. However, there is still a lack of data to support improved outcomes with IV push antibiotics compared to IV piggyback administration. Due to septic patients frequently requiring multiple antibiotics and concomitant interventions, IV push antibiotics make an attractive option, especially within the first several hours of care. While faster administration is one of the primary benefits of IV push administration, it also requires less total fluid volume, making it an ideal modality in patients with fluid restrictions. Additionally, IV push antibiotics are easily stored in automated dispensing cabinets and do not require small-volume parenteral solutions, which are commonly in short supply. One study found that 87% of ED nurses favored IV push administration due to less time spent gathering equipment and infusion supplies, entering nursing orders for carrier fluids, and documenting secondary infusions. [2]
A potential benefit of IV push antibiotic administration is cost savings. Use of intravenous tubing, diluent bags, and staff time (e.g., preparation, pharmacist review, nurse administration) is reduced by reconstituting antibiotics with 10 to 20 mL of diluent at the bedside. The expiration date is also extended when compared to the IV piggyback route, minimizing drug waste. With respect to safety, IV push beta-lactams appear to be as safe as IV piggyback/infusion, with no study to date demonstrating a significantly increased risk of adverse effects. However, IV push antibiotics generally have higher sodium concentrations and osmolalities compared to IV piggyback, which may lead to infiltration, local irritation, and phlebitis. Despite this caveat, available data have typically found IV push antibiotics to be well tolerated; use of sterile water for injection instead of 0.9% sodium chloride or 5% dextrose may minimize the osmolality to mitigate the risk of phlebitis. Overall, IV push antibiotics appear to be as safe and effective compared to IV infusions, with potential benefits including decreased time to antimicrobial administration, enhanced nursing satisfaction, and lower healthcare costs. [2]
Several retrospective studies have investigated IV push and IV piggyback cephalosporins. A 2024 retrospective study compared the rate of treatment failure in obese (n= 206) and non-obese (n= 187) intensive care unit patients receiving IV push and IV piggyback ceftriaxone. The primary outcome, treatment failure, was defined as a composite of antibiotic escalation and all-cause mortality. Among the included non-obese and obese patients, 47% and 55% received IV push ceftriaxone, respectively. The primary outcome of treatment failure showed no significant difference between non-obese and obese patients (28% vs. 30%; p= 0.696). Additionally, subgroup analyses based on the administration method revealed no significant differences (IV push: non-obese 38% vs. obese 38%; p= 0.967; IV piggyback: non-obese 19% vs. obese 20%; p= 0.866). Notably, secondary outcomes encompassing the individual components of the composite outcome, costs of therapy, and length of stay also did not exhibit any significant differences. Overall, these findings suggest that obesity did not contribute to worse outcomes with either IV push or IV piggyback administration. However, given that only the abstract was available, a comprehensive analysis of the study could not be conducted. [3]
A 2021 abstract describes a retrospective study aimed to evaluate the incidence of infusion-related complications in patients receiving cefazolin, ceftriaxone, and cefepime administered via IV push versus short infusion IV piggyback. IVP or IV piggyback administration complications were evaluated from a chart review of electronic medical records. A total of 366 therapy sessions from 355 individual patients were included for analysis. In the IV push group, complications occurred in 13 of 183 treatment episodes (7.1%) compared to 18 of 183 (9.8%) in the IV piggyback group (p = 0.35). For both groups, the median time to complications was two days. The median time to the first dose of vancomycin in the ED was 25 minutes shorter with IV push cefepime and ceftriaxone. Additionally, the use of cefazolin, ceftriaxone, and cefepime as IV push yielded quarterly cost savings of $38,890.04. Notably, 55% of nursing staff and 85% of pharmacy staff preferred IV push administration for cefazolin, ceftriaxone, and cefepime. Cefazolin, ceftriaxone, and cefepime administered as IV push were found to be as safe as IV piggyback while lowering the time to the first dose of vancomycin in the ED and cost. [4]
Finally, a 2019 retrospective analysis assessed the safety and efficacy of transitioning from intermittent IV infusion to slow IV push administration of cefepime, ceftriaxone, and meropenem. A total of 108 patients were included in the analysis, specifically evaluating clinical improvement, with 57 patients in the intermittent IV infusion group and 51 in the slow IV push group. Notably, the analysis revealed no significant differences between the intermittent IV infusion and slow IV push groups in terms of clinical improvement 48 hours after antibiotic initiation (43.3% vs. 47.8%; p= 0.79), antibiotic duration (6.07+2.90 days vs. 5.57+2.52 days; p= 0.34), peripherally inserted central catheter or midline placement (59.6% vs. 47.1%; p= 0.25), or death (1.8% vs. 3.9%; p= 0.60). These results suggest that transitioning from intermittent IV infusion to slow IV push administration of cefepime, ceftriaxone, and meropenem did not yield statistically significant differences in the assessed endpoints, indicating comparable outcomes between the two administration methods. However, it is important to note that only the abstract of this study was available for scrutiny. [5]
A 2024 multicenter, retrospective practice research report compared IVP versus IVPB antibiotic administration across six emergency departments within a 1,250-bed healthcare system. The investigation focused on adult patients (≥18 years) who received a single dose of IVP or IVPB ceftriaxone, cefepime, cefazolin, or meropenem. IVP administration protocols were implemented alongside educational handouts and order set modifications that included bedside reconstitution and administration instructions. The study population included 43 patients in each group, selected based on matched antibiotic dosing and emergency department location, with the IVPB cohort identified in January 2022 and the IVP cohort between November and December 2022. According to the report, IVP antibiotics significantly reduced the median time from order placement to administration initiation—31 minutes (IQR, 21–52) versus 74 minutes (IQR, 29–114) with IVPB (p = 0.003). Moreover, the median cost per dose was notably lower for IVP agents when compared to IVPB preparations: $3.31 vs $20.59 for ceftriaxone (p <0.001), $7.11 vs $45.84 for cefepime (p <0.001), and $2.37 vs $7.03 for meropenem (p = 0.029). Annual cost savings were estimated to exceed $227,000 across the emergency departments due to reduced reliance on expensive IVPB premixes and associated materials. A nursing satisfaction survey revealed widespread acceptance, with 76% of respondents preferring IVP over IVPB and 87% reporting perceived reductions in time to administration. These results highlight that IVP antibiotic protocols can improve timeliness of care, enhance resource utilization, and support sepsis treatment guidelines that emphasize antibiotic administration within one hour of recognition. [6]
Lastly, a 2012 prospective, quasi-experimental study evaluated postinfusion phlebitis rates in 240 adult orthopedic surgical patients receiving cefazolin prophylaxis via two different infusion methods, IVP and IVPB. Patients were divided into two sequential groups of 120; the first group received cefazolin via IVPB over 30 minutes, while the second group received the same medication via IVP over 3 to 10 minutes, contingent upon the dosage. All patients received between 1 and 5 doses of IV cefazolin and had IV lines in place for 1 to 4 days. Results indicated no statistically significant difference in phlebitis rates between the two methods, with incidences reported at 3.4% for the IVPB cohort and 3.3% for the IVP cohort. Phlebitis cases in the IVP group were all grade 1, whereas the IVPB group observed two grade 2 cases. Although a multivariate analysis was not feasible given the limited number of phlebitis cases, univariate analysis highlighted the total catheter-days as the sole significant predictor (p<0.01). Despite variances in adjuvant IV analgesics, such as morphine and hydromorphone being more common in the IVP cohort compared to ketorolac and prochlorperazine in the IVPB group, these differences did not affect phlebitis outcomes. Overall, these findings highlight that administering cefazolin via IVP is a cost-effective alternative that does not compromise patient safety or vascular access site integrity. [7]