Best Practices for Antibiotic Administration in Medical Settings
Establish a comprehensive antimicrobial stewardship program with a local antibiotic policy and formulary, implement restricted lists of key agents, ensure appropriate empirical therapy selection with rapid de-escalation based on culture results, and optimize dosing using pharmacokinetic principles while maintaining rigorous audit cycles. 1
Core Administrative Framework
Institutional Requirements
Create and maintain a local antibiotic policy and formulary through widespread multidisciplinary consultation involving prescribers, pharmacists, and infection specialists, updated regularly based on local resistance patterns 1
Establish a multidisciplinary drugs and therapeutics committee (or dedicated antibiotic committee) with transparent proceedings and declared conflicts of interest to review agents and introduce new drugs 1
Implement restricted lists of key agents with evidence showing this has the strongest support among all stewardship interventions 1
Measure and benchmark antibiotic consumption regularly with discussion between prescribers, pharmacists, and infection specialists 1
Conduct systematic audits of doses, duration, and route of administration with documented process and outcome measures 1
Clinical Practice Standards
Diagnostic Rigor Before Treatment
Document clinical and laboratory evidence supporting bacterial infection before initiating antibiotics, including sepsis parameters: temperature, respiratory rate, pulse, blood pressure, white blood cell count, and C-reactive protein 1
Obtain appropriate cultures before antibiotic initiation whenever possible, though treatment must not be delayed in critically ill patients 1
Consider watchful waiting for potentially self-resolving infections, chronic infections, or cases requiring further diagnostic testing before antibiotic initiation, with structured monitoring through scheduled follow-up calls or in-person visits 1
Empirical Therapy Selection
Use evidence-based treatment guidelines that are readily accessible, drawn up with multidisciplinary involvement, peer-reviewed, and compatible with national guidelines 1
Initiate appropriate empirical therapy immediately in critically ill patients—treatment (intravenous if necessary) must not be delayed even for half an hour 1
Limit treatment to bacterial infections using antibiotics directed against the causative agent, given in optimal dosage, interval, and duration only when benefits outweigh individual and global risks 1
Therapy Optimization and De-escalation
Streamline antibiotic therapy at the earliest opportunity using laboratory test results to rationalize treatment, avoiding prolonged use of broad-spectrum antibiotics as a substitute for accurate diagnosis 1
Optimize dosing schedules according to the latest pharmacodynamic evidence to maximize patient outcomes and reduce resistance emergence 1
Monitor therapeutic drug levels especially for antibiotics with narrow toxic/therapeutic ratios and in patients with renal impairment 2
De-escalate to narrow-spectrum monotherapy rapidly once culture results and clinical response allow 2
Shorten treatment duration whenever clinically appropriate rather than defaulting to extended courses 2
Special Considerations
Emergency Department Context
Address unique ED challenges including rapid patient turnover, diagnostic uncertainty, incomplete data during transitions of care, crowding-associated cognitive load, and perceived patient expectations 1
Implement structured follow-up systems for outpatients discharged from the ED with or without antimicrobial therapy and pending microbiological cultures 1
Conduct diagnostic analysis before implementing guideline recommendations, using behavioral science principles to identify facilitators and barriers specific to each practice and setting 1
Surgical Prophylaxis
Advocate single-dose prophylaxis for the vast majority of surgical procedures based on evidence-based guidelines 1
Calculate numbers needed for prophylaxis using baseline infection risk and prophylaxis efficacy data to make rational decisions about prophylaxis in debated areas 1
Drug-Specific Administration
Administer vancomycin as diluted solution over at least 60 minutes to avoid rapid-infusion-related reactions including exaggerated hypotension, shock, and rarely cardiac arrest 3
Adjust vancomycin dosing for renal dysfunction as the risk of nephrotoxicity and ototoxicity increases appreciably with high, prolonged blood concentrations 3
Use prolonged or continuous beta-lactam infusions when appropriate, as this is safe and may improve outcomes 2
Implementation Strategy
Behavioral and Systemic Factors
Perform systematic diagnostic analysis for each specific prescribing practice separately, as each elicits its own pattern of facilitators and barriers through interviews, questionnaires, or observation 1
Address recurrent barriers including diagnostic uncertainty, incomplete data, crowding, perceived patient expectations, non-guideline-compliant working environments, and poor access to follow-up care 1
Ensure adequate flushing of intravenous lines between administration of incompatible antibiotics, particularly vancomycin and beta-lactam antibiotics which are physically incompatible 3
Common Pitfalls to Avoid
Do not use broad-spectrum antibiotics as a substitute for accurate diagnosis despite their perceived safety 1
Avoid prescribing antibiotics to approximately 50% of ICU patients who receive them without confirmed infections 2
Do not neglect de-escalation and shortened treatment duration, which are infrequently performed despite strong evidence supporting these practices 2
Recognize that antibiotic-induced microbiota changes alter immune and metabolic systems and encourage emergence of resistant organisms 2