Jasmin Adebisi
Policy Manager – Health, Policy Connect
Ruth Dando
Head of Nursing for Critical Care and Theatres at Barking, Havering and Redbridge University Hospitals NHS Trust
Underdosing IV antibiotics is a growing healthcare concern, impacting clinical outcomes, financial and operational efficiency and the environment.
Underdosing occurs as residual IV antibiotic fluid remains in the tubing of administration sets (drip) at the end of the infusion. In the absence of flushing the line, patients can miss out on between 20%–40% of the prescribed dose when the administration set is disconnected and discarded.1
Antibiotic underdosing risks resistance
Inadequate delivery of total prescribed doses may fail to fully eradicate the infecting pathogen, increasing the risk of treatment failure and the development of antibiotic resistance. Patients with sepsis, a life-threatening infection, require prompt and aggressive antibiotic treatment. Underdosing could increase the risk of mortality. Additionally, incorrect disposal of remnants of antibiotics in unflushed lines contributes to environmental contamination which is regarded as a strong driver of antimicrobial resistance.
How to combat drug resistance
The implications of IV antibiotic underdosing also extend beyond individual patient outcomes as subtherapeutic antibiotic levels can contribute to the emergence of drug-resistant bacteria. This global health issue poses a threat to future treatment options, as infections caused by resistant organisms are more difficult and expensive to treat.
All healthcare providers must
adopt line flushing protocols.
Flushing the administration set with saline or other compatible diluent is a straightforward yet effective solution. A recent report1 calls for a coordinated, UK-wide effort to implement antibiotic line flushing. It urges collaboration across sectors and support from the Department of Health and Social Care.
Need for line flushing protocols
Drug-resistant infections cost the NHS millions annually. Knowing that underdosing potentially contributes to this, all healthcare providers must adopt line flushing protocols so that full doses of medications are delivered. Reducing underdosing ensures safe, effective care is delivered to achieve the best patient outcomes, combats antimicrobial resistance processes and reduces drug-resistant infections while driving down unnecessary costs.
Barking, Havering and Redbridge University Hospitals NHS Trust, along with several other Trusts, have reinstated line flushing practices. I implore that all other institutions do the same to ensure that every NHS patient requiring IV antibiotics receives the complete prescribed dose. Policy Connect and the APPG for Health are set to embark on work next year, which will explore how the NHS and government stakeholders can collaborate to address this disparity in healthcare delivery.
[1] Fady, P.-E., & Bennett, N. (2023). Antibiotic underdosing and disposal in NHS organisations across Great Britain (1.0.2). Office of Baroness Bennett of Manor Castle. https://doi.org/10.5281/zenodo.10284305.
