Devices for parenteral drug delivery and intravenous access used in ambulatory antimicrobial therapy

The ambulatory antimicrobial therapy team is responsible for the choice of drug delivery device and intravenous access device. Relevant factors include:

• duration of treatment
• concentration and potential for the antimicrobial to cause vascular irritation
• ease of vascular access
• number of drugs to be administered
• patient acceptability
• cost
• potential for complications, particularly sepsis.

In patients with chronic kidney disease who may need fistula formation in future for haemodialysis, the position of the vascular access device requires careful consideration and discussion with the nephrologist or vascular surgeon. Upper limb peripherally inserted central catheters (PICCs) are particularly problematic in this situation, and tunnelled central venous catheters (CVCs) may be a better option in some patients.

Drug delivery devices used in ambulatory parenteral antimicrobial therapy include elastomeric infusor devices, electronic programmable infusion pumps and syringe infusion pumps. Drugs can also be delivered by intravenous injection or intermittent intravenous infusion, without a pump.

Intravenous access devices used for drug administration in ambulatory parenteral antimicrobial therapy include central intravenous access devices, midline catheters and peripheral intravenous cannulae – each has advantages and disadvantagesNorris, 2019.

Central intravenous access devices include peripherally inserted central catheters (PICCs), tunnelled central venous catheters (CVCs) and implanted ports. Nontunnelled CVCs (eg subclavian or jugular CVCs) are not recommended for ambulatory antimicrobial therapy because they are associated with a higher complication rate than tunnelled CVCs. Central intravenous access devices are used for intermittent dosing or continuous infusion. They can be left in place for weeks to months when there are no complications, with duration dependent on the device.

Midline catheters are peripherally inserted catheters. The tip is located at or below the axillary vein. They can remain in place for up to 4 weeks and are an alternative to PICC lines. Midline catheters are used for intermittent dosing or continuous infusion of drugs that do not cause vascular irritationInfectious Diseases Society of America (IDSA), 2016.

Peripheral intravenous cannulae (PIVC) are usually only suitable for a short duration (up to 7 days) of ambulatory parenteral antimicrobial therapy, with drugs that do not cause vascular irritation. Patients must have adequate vascular access. PIVCs can be used for intravenous injection or intravenous intermittent infusion. They are generally not recommended for continuous infusion because of the risk of failure of the device and associated problems (eg extravasation, interruption of drug therapy). PIVCs should be changed in accordance with the Australian Commission on Safety and Quality in Health Care (ACSQHC) Quality statement; common practice is to replace a PIVC at least every 3 daysAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2021. For therapy longer than 7 days, a central line or midline catheter should be used instead.

For information on managing and monitoring intravenous access devices, see Key points for managing and monitoring intravenous access devices. Each type of device has a risk of catheter-related adverse events, most commonly local infection, sepsis or deep vein thrombosis. The rate of device complications should be regularly audited by the ambulatory antimicrobial therapy service. A complication rate of less than 1 per 1000 catheter-days is usually considered acceptableAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2021.

Staff that administer antimicrobials using intravenous access devices must be trained and competent.