What is the exposure infusion protocol?

From the Guidelines

The expose infusion protocol should be performed in a controlled setting with emergency equipment readily available, starting with a low dose and gradually increasing it, while continuously monitoring vital signs and keeping medications like epinephrine, antihistamines, and corticosteroids ready to treat any allergic reactions, as recommended by the most recent guidelines 1.

Key Considerations

• The protocol typically begins with a very low dose of the medication, often 1/10,000 of the therapeutic dose, administered intravenously in a controlled setting with emergency equipment readily available.
• The dose is then incrementally increased every 15-30 minutes, doubling each time, until the full therapeutic dose is reached.
• Common medications used in desensitization include antibiotics (particularly beta-lactams like penicillin), chemotherapeutic agents, and biologics.
• Throughout the procedure, vital signs are continuously monitored, and medications like epinephrine, antihistamines, and corticosteroids are kept ready to treat any allergic reactions.

Management of Infusion Reactions

• For mild reactions, the infusion rate may be decreased or temporarily interrupted until resolution of the event, as recommended by the Society for Immunotherapy of Cancer 1.
• For moderate reactions, consider reducing the rate of infusion upon re-initiation or subsequent infusions, and use non-steroidal anti-inflammatory drugs (NSAIDs), antihistamines, opioids, and corticosteroids as needed, as recommended by the European Society for Medical Oncology 1.
• For severe reactions, permanently discontinue the infusion and manage the patient as clinically appropriate, as recommended by the Society for Immunotherapy of Cancer 1.

Important Notes

• The expose infusion protocol must be performed in a hospital setting under close supervision by allergists or immunologists, as there is a risk of anaphylaxis.
• This desensitization is temporary, lasting only as long as the medication is continuously administered.
• The protocol should be tailored to the individual patient's needs and medical history, taking into account the specific medication and reaction severity, as recommended by the most recent guidelines 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION 500 mg every 8 hours by intravenous infusion over 15 to 30 minutes for complicated skin and skin structure infections (cSSSI) for adult patients. 1 gram every 8 hours by intravenous infusion over 15 minutes to 30 minutes for intra-abdominal infections for adult patients. Intravenous infusion is to be given over approximately 15 minutes to 30 minutes.

The exposure infusion protocol for meropenem (IV) is 15 to 30 minutes for adult patients with complicated skin and skin structure infections or intra-abdominal infections 2.

• For pediatric patients 3 months of age and older, the infusion protocol is also 15 to 30 minutes.
• For pediatric patients less than 3 months of age, the infusion protocol is 30 minutes.

From the Research

Expose Infusion Protocol

• The expose infusion protocol for meropenem involves administering the antibiotic through continuous infusion or intermittent bolus injection 3, 4, 5, 6, 7.
• Studies have shown that continuous infusion of meropenem can be beneficial in achieving higher drug concentrations and improving clinical outcomes in critically ill patients 3, 5, 6.
• The daily dose of meropenem commonly ranges from 3 to 6 g/day, with critically ill patients and those with impaired renal function being the most suitable candidates for therapeutic drug monitoring (TDM) 4.
• TDM can help maximize clinical outcomes by guiding therapy and preventing failure, toxicity, and antimicrobial resistance 4.
• Prolonged infusion time has been shown to improve the therapeutic effect of meropenem, especially when the minimum inhibitory concentration (MIC) is less than 4 mg/L 5.
• The addition of colistin to meropenem has been shown to improve its activity against Pseudomonas aeruginosa biofilms, with extended infusion regimens being more effective than intermittent bolus injections 6.
• Outpatient parenteral antimicrobial therapy (OPAT) with continuous infusion of meropenem has been shown to be a viable option for selected patients, with a low rate of adverse reactions and readmissions 7.

Key Findings

• Continuous infusion of meropenem can achieve higher drug concentrations and improve clinical outcomes in critically ill patients 3, 5, 6.
• TDM is essential in guiding therapy and preventing failure, toxicity, and antimicrobial resistance in critically ill patients and those with impaired renal function 4.
• Prolonged infusion time can improve the therapeutic effect of meropenem, especially when the MIC is less than 4 mg/L 5.
• The addition of colistin to meropenem can improve its activity against Pseudomonas aeruginosa biofilms 6.
• OPAT with continuous infusion of meropenem can be a viable option for selected patients, with a low rate of adverse reactions and readmissions 7.

Meropenem Administration

• Meropenem can be administered through continuous infusion or intermittent bolus injection 3, 4, 5, 6, 7.
• The choice of administration method depends on the patient's condition, renal function, and the severity of the infection 3, 4, 5.
• Continuous infusion of meropenem has been shown to be beneficial in achieving higher drug concentrations and improving clinical outcomes in critically ill patients 3, 5, 6.