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Updated: Sep 21, 2025
Multiplex Therapeutic Drug Monitoring by Isotope-dilution HPLC-MS/MS of Antibiotics in Critical Illnesses
Published on: August 30, 2018
Drowning in antibiotics
C L Gelder1, S Robinson2, F Leitch1
1NHS Greater Glasgow and Clyde, UK.
Introduction:
The National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended that 'fluid prescribing be given the same value as drug prescribing', yet fluid prescription is commonly delegated to junior doctors despite being a notoriously challenging topic. When antibiotics are given as an infusion they are diluted in 100ml of fluid, which is often unaccounted for when thinking about a patient's fluid requirements. This closed-loop audit aimed to assess first, intravenous (IV) fluid therapy and second, electrolyte prescribing compliance with National Institute for Health and Care Excellence (NICE) guidelines, with and without the additional fluid given with antibiotic administration.
Methods:
Two retrospective audits were performed. Total fluid and electrolyte volume received with and without antibiotic fluids was correlated with recommendations in the NICE guidelines. Between cycles 1 and 2, potassium chloride with sodium chloride and glucose (PSG) was introduced as an alternative to IV maintenance fluid, and bolusing of antibiotics was mandatory.
Results:
When analysing total fluid volume input per day, 10.4% and 7.45% of patients met their fluid requirement accurately in the first and second cycles, respectively. Within cycle 1, the mean total additional fluid that was given over 3 days with antibiotics was 1,572.73ml. In cycle 2, this decreased to 469.44ml when antibiotics were given as a bolus.
Conclusions:
In this closed-loop audit we noted that patients receiving IV fluids and IV antibiotics received too much additional fluid when the antibiotic dilution fluid was taken into account. Additional fluid was reduced alongside the proportion of electrolyte complications when bolusing of antibiotics was introduced. We recommend that that all nurses are trained to give antibiotics as a bolus because it can help to reduce fluid-related complications.
Insights
Intravenous fluid prescribing is complex, especially when antibiotics are included. Bolusing antibiotics, instead of infusing them, significantly reduced excess fluid administration and electrolyte complications in a recent audit.
Area of Science:
- Medical Auditing
- Patient Safety
- Fluid Management
Background:
- The National Confidential Enquiry into Perioperative Deaths (NCEPOD) highlighted the critical importance of intravenous (IV) fluid prescribing, recommending it receive the same attention as drug prescribing.
- Fluid prescription is often managed by junior doctors, despite its complexity, and the fluid used to dilute antibiotics is frequently overlooked in daily fluid balance calculations.
Purpose of the Study:
- To conduct a closed-loop audit assessing compliance with National Institute for Health and Care Excellence (NICE) guidelines for intravenous (IV) fluid and electrolyte therapy.
- To evaluate the impact of additional fluid administered with antibiotics on overall fluid balance and electrolyte prescribing.
Main Methods:
- Two retrospective audit cycles were performed to analyze total fluid and electrolyte intake.
- Compliance with NICE guidelines was assessed, comparing fluid administration with and without the inclusion of antibiotic dilution fluid.
- Changes in practice between cycles included the introduction of potassium chloride with sodium chloride and glucose (PSG) and mandatory antibiotic bolusing.
Main Results:
- In the first audit cycle, only 10.4% of patients accurately met their daily fluid requirements. This improved slightly to 7.45% in the second cycle.
- The mean additional fluid volume administered with antibiotics over 3 days was 1,572.73ml in cycle 1.
- Following the introduction of mandatory antibiotic bolusing in cycle 2, this additional fluid volume decreased significantly to 469.44ml.
Conclusions:
- Patients receiving IV fluids and IV antibiotics often receive excessive fluid when the dilution volume of antibiotics is considered.
- Implementing antibiotic bolusing reduced both the amount of additional fluid and the incidence of electrolyte complications.
- Training nurses to administer antibiotics as a bolus is recommended to mitigate fluid-related complications and improve patient safety.
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