Which antibiotics can be administered via intravenous (IV) push?

Which Antibiotics Can Be Administered via IV Push

Several beta-lactam antibiotics are FDA-approved for IV push administration, and additional antibiotics including cefepime, ceftriaxone, ertapenem, gentamicin, and tobramycin have primary literature supporting this route, though extended infusions remain preferred for critically ill patients with severe sepsis. 1

FDA-Approved IV Push Antibiotics

Beta-Lactams with Established IV Push Administration

• Many beta-lactam antibiotics are FDA-approved for IV push administration, providing clinical advantages in emergency departments, fluid-restricted patients, and during diluent shortages 1
• Piperacillin-tazobactam can be administered via IV push after reconstitution and dilution to appropriate concentrations, though the FDA label primarily describes infusion over at least 30 minutes 2
• Recent evidence demonstrates that piperacillin-tazobactam IV push (5 minutes) reduced time to antibiotic administration by 9 minutes compared to IV piggyback (30 minutes) in emergency department sepsis patients, with no difference in hypersensitivity reactions or mortality 3

Aminoglycosides

• Gentamicin and tobramycin have primary literature data supporting IV push administration 1
• Standard dosing for gentamicin is 2-2.5 mg/kg every 8 hours for children ≥5 years, with once-daily dosing preferred for concentration-dependent killing 4
• Tobramycin dosing varies by age: preterm neonates <1000g receive 3.5 mg/kg every 24 hours, while children ≥5 years receive 2-2.5 mg/kg every 8 hours 4

Cephalosporins

• Cefepime and ceftriaxone have primary literature supporting IV push administration 1
• Ceftriaxone can be given once daily due to its long half-life, making it particularly suitable for outpatient parenteral antimicrobial therapy 4

Carbapenems

• Ertapenem has primary literature supporting IV push administration 1
• Meropenem administered via extended infusion (EI) achieved clinical stability faster than IV push (median 20.4 vs 66.2 hours, p=0.01), with shorter ICU length of stay (6 vs 9 days, p=0.02) 5

Antibiotics NOT Recommended for IV Push

Limited or Unsupportive Data

• Amikacin, ciprofloxacin, imipenem/cilastatin, and metronidazole have limited primary literature, and available data do not support IV push administration 1
• Vancomycin requires infusion over 30-60 minutes to prevent red man syndrome and should not be given as IV push 4

Critical Pharmacodynamic Considerations

Time-Dependent vs Concentration-Dependent Killing

• Beta-lactams demonstrate time-dependent killing and require maintaining serum concentrations above the MIC for optimal efficacy 4, 6
• Extended infusions of 3-4 hours for beta-lactams in critically ill patients with severe sepsis reduced mortality from 16.8% to 10.8% (p=0.03) compared to standard 30-minute infusions 6
• Aminoglycosides show concentration-dependent killing with prolonged post-antibiotic effect, making once-daily dosing appropriate 4

Clinical Outcomes with IV Push Beta-Lactams

• A retrospective study of 213 patients with gram-negative bacteremia found no significant differences in clinical response, microbiological clearance, or mortality between IV push (5 minutes) and IV piggyback (30 minutes) administration of cefepime or meropenem 7
• However, for critically ill patients, extended infusions should be prioritized to maintain adequate pharmacodynamic targets 6, 5

Practical Administration Guidelines

Standard IV Push Technique

• Beta-lactams approved for IV push should be reconstituted and diluted according to manufacturer specifications 1
• Administration time for IV push is typically 3-5 minutes, compared to 30-60 minutes for standard infusions 3, 7
• The initial dose should be administered in a supervised setting with personnel trained in resuscitation and appropriate equipment readily available 4

Special Populations Requiring Caution

• Once-daily aminoglycoside dosing has not been fully evaluated in pregnant women, children, elderly persons, critically ill patients, or those with renal dysfunction, neutropenia, burns, liver disease, or endocarditis 4
• Tetracyclines should be avoided in young children due to dental staining 8

Common Pitfalls to Avoid

• Do not administer vancomycin, amphotericin B, acyclovir, ganciclovir, or foscarnet via IV push due to infusion rate-dependent toxicities 4
• Aminoglycosides should not be mixed with piperacillin-tazobactam due to in vitro inactivation; they must be reconstituted, diluted, and administered separately 2
• For critically ill patients with severe sepsis, standard 30-minute beta-lactam infusions may be inadequate, and extended 3-4 hour infusions should be considered 6