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Dilution Guideline Injectable Drugs Part I Antimicrobial April 2021 PDF 0
Dilution Guideline Injectable Drugs Part I Antimicrobial April 2021 PDF 0
20(GU)-e
DILUTION GUIDELINE
FOR INJECTABLE DRUGS
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
MOH/S/FAR/11.20(GU)-e
No. Rujukan: A-GU-84
No. Keluaran: 1
Permission is hereby granted to reproduce inform ation contained herein provided that such
reproduction be given due ack nowledgem ent and shall n o t m odif y the text. Enquiries are to be
directed to the address below.
Summary Dilution Guideline for Injectable Drugs serves as a general reference for
healthcare professionals on the preparation of injectable drugs before
administering to the patient.
1
Applies to All government and private healthcare facilities
TABLE OF CONTENT
PAGE
CONTENT NUMBER
Disclaimer 4
Preface 4
Foreword 5
Ac k nowledgem ent 6
Reviewers 6
Accreditors 7
Editorial Board 8
Abbreviations & Acronyms 9
List of Drugs
■ Acyclovir Injection 10
■ Am ik acin Injection 11
■ Amoxicillin & Clavulanate Injection 12
■ Am photericin B Injection 13
2 ■ Am picillin Injection 14
■ Am picillin & Sulbactam Injection 15
■ Anidulafungin Injection 16
■ Artesunate Injection 17
■ Azithrom ycin Injection 18
■ Benzathine Penicillin Injection 19
■ Benzylpenicillin Injection 20
■ Caspofungin Acetate Injection 21
■ Cefazolin Injection 23
■ Cefepime Injection 24
■ Cefoperazone Injection 25
■ Cefoperazone & Sulbactam Injection 26
■ Cefotaxime Injection 27
■ Ceftazidime Injection 28
■ Ceftriaxone Injection 29
■ Cefuroxime Injection 31
■ Clindamycin Injection 32
■ Cloxacillin Injection 33
■ Ertapenem Injection 34
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
PAGE
CONTENT NUMBER
DISCLAIMER
This guideline serves as a general reference for the healthcare professionals in the Ministry of
Health on h o w to prepare dilution of certain injectable drugs before administering to the patient.
The inform ation provided in this guideline m ainly extracted f r o m the package insert for the
brand of injectable drugs used and valid at the t i m e of publication. Nevertheless, users are
strongly advised to refer to the dilution instruction as stated in the produc t package insert
currently used at the respective facilities and update regularly.
The medicines included in this guideline are selected f r o m the Ministry of Health Medicines
Formulary (MOHMF).
The users of this guideline m u s t have the necessary k nowledge and c om peten c y in ord er to
interpret the inform ation provided. In no event shall the Pharmaceutical Services Program m e
be liable for any direct, indirect, incidental, special or consequential event resulting f r o m the
use of or the inability to use this guideline. The c om m ittee reserves the right to am end, update
or remove the content of this guideline when necessary.
PREFACE
The Malaysian National Patient Safety Council Technical Com m ittee on Medication Safety had
p u t in m u c h effort t h r oug h the various stakeholders to p rom ote m edication safety culture in both
the public and private healthcare sector. The prim ary goal of m edication safety is to ensure long
4 t e r m and continuous quality im provem ents in healthcare. One way of achieving it is by
im proving and strengthening m edic ation safe practice. Hence, Pharmaceutical Services
Programme, Ministry of Health Malaysia has tak en the initiative and prepared the Dilution
Guideline for Injectable Drugs.
The purpose of this guideline is to provide inform ation and facilitate the healthcare professionals
at all levels in the preparation of injectable drugs that are listed in the Ministry of Health
(MOH) d r u g formulary wh ic h requires dilution. This guideline will also serve as a preventive
measure to reduce medication errors related to incorrect dilution and adm inistration of
injectable drugs.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
FOREWORD
Medication safety has received m u c h attention administration of these drugs. There are a few
after the Institute of Medicine had published “To types of medication errors related to injectable
Err Is Human: Building a Safer Health System” drugs that are comm only reported to
report which was in line with the third World Medication Error Reporting System (MERS), for
Health Organization (WHO) Global Patient example: incorrect dilution, incorrect route of
Safety Challenge. Errors can never be entirely administration, incorrect infusion rate and
eliminated, b u t their numbers and severity can be incorrect diluent. Thus, prom oting safe injection
reduced. The occurrence of medication errors can practices and establishment of standard for
compromise patients’ confidence in healthcare dilution and administration of injectable drugs
system by exposing t h em to the risk of adverse are crucial to ensure patient safety.
drug reactions and increased healthcare cost.
Ensuring safer care for every patient, every time,
Moreover, medication errors are preventable.
everywhere is the vision established by W HO as
The Malaysian Patient Safety Council, Ministry of the goals towards continuous improvements in
Health (MOH) had p u t in m u c h effort through patient safety and m anaging risks to prevent 5
the various stakeholders to promote medication harm (particularly “avoidable harm” during
safety culture in both the public and private treatment and care). Hence, medication safety
healthcare sectors. Pharmaceutical Services is everyone’s responsibility so as to make the
Programme, MOH has been given a mandate to healthcare system safer. This guideline aims to
lead the Technical W orking Group of Medication facilitate the healthcare personnel in preparing
Safety at the national level. The committee, which the dilutions of drugs which are available in the
comprises various stakeholders, will identify any MOH drug lists. The availability of this guideline
issues related to medication safety and plan for will assist in the expansion of quality clinical care
ongoing improvements in the quality and safety pharmacy services throughout MOH facilities.
of the medication m anagem ent system and
I would like to congratulate the editorial
practices.
committee, accreditors and reviewers for their
W ith the aim of reducing the risks related to efforts and contributions in the development
injectable drugs, initiatives have been taken to of this dilution guideline. It is hoped that this
establish Dilution Guidelines for Injectable guideline would be a useful reference for all who
Drugs to promote safe medication use. Moreover, are involved in the dilution and administration of
errors in intravenously administered medications injectable drugs in the healthcare facilities.
may have serious consequences and incident
can happen during preparation,dispensing and All the best and thank you.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
ACKNOWLEDGEMENT
Special thanks dedicated to everyone who were involved directly or indirectly in the establishment of
this guideline.
This guideline consumes enormous amount of work, time efforts and dedication. Thus,
Pharmaceutical Services Programme, Ministry of Health would like to extend our utmost gratitude to
all individuals and organizations that had provided valuable input, advice and information for this
guideline.
We are also grateful for the provision of expertise and technical support in the development of this
guideline. Hopefully, the information provided can lead to the improvements in quality and safe
medication practice.
REVIEWERS
◆ Mdm Poh Wei Yoon ◆ Mdm Nor Mazni Binti Mohamad Tamyes
Pharmacist Pharmacist
Selayang Hospital Tengku Am puan Rahimah Hospital
◆ Mdm Noor Liyana Binti Yusup ◆ Mr. Muhammad Faizal Bin Maarof
Pharmacist Pharmacist
Rantau Panjang Health Clinic Tuanku Am puan Najihah Hospital
ACCREDITORS
◆ Mdm Fajaratunur Binti A. Sani ◆ Mr. Ahmad Ridza Bin Ahmad Nizam
Pharmacist Pharmacist
Johor Bahru District Health Office Tuanku A m p u a n Najihah Hospital
◆ Mdm Nur Mariana Binti Ayub ◆ Mdm Nurul Husna Binti Sodri
Pharmacist Pharmacist
Kajang Hospital Pharmacy Practice & Developm ent Division
Selangor State Health Departm ent
7
◆ Mdm Wong Siew Ling ◆ Mdm Kasidah Binti Kasran
Nursing Matron Nursing Sister
Selayang Hospital Shah Alam Hospital
EDITORIAL BOARD
ADVISOR
EDITORIAL COMMITTEE
BW body weight
D5 5% dextrose
g gram
gtt drops
HCl hydrochloride
IM intram uscular
IV intravenous
kg k ilogram 9
L litre
m ax m axim um
mcg m ic rogram
mg m illigram
ml millilitre
RT r o o m tem perature
SC subcutaneous
Acyclovir Injection
Diluents
NS
10
Adm inistration IV infusion
Adm inister by slow IV infusion over 1 hour.
*Protect f r o m light.
*Reconstituted or diluted solutions SHOULD NOT BE REFRIGERATED.
References 1. Product leaflet Vaxcel® Acyclovir IV For Infusion (Kotra Pharm a (M)
Sdn. Bhd, Malaysia). Revised date: 2.4.2019.
2. Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill
Professional.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Amikacin Injection
Diluents
NS, D5
Adm inistration IM
IV infusion
■ Adult: Adm inister slowly over 30 – 60 minutes.
■ Infants: Adm inister slowly over 1 – 2 hours.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Diluents
NS, W FI
IV infusion
Adm inister over 30 – 40 m inutes and com plete wi th i n the t i m e
stated.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Amphotericin B Injection
Diluent
D5
References 1. Product leaflet Photericin B For Injection USP (Cipla LTD, India).
2. Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill
Professional.
* The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Ampicillin Injection
Reconstitution IV
Dissolve 1 vial (500m g) in 10 ml WFI.
IM
Dilute 1 vial (500m g) wi t h 1.5 ml WFI.
Diluent
NS
Intermittent IV infusion
Adm inister over 15 – 30 minutes.
IM
14
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Reconstitution IV
■ Reconstitute 1 vial (1. 5 g) wi t h 3.2 m l WFI.
■ To ensure com plete dissolution, allow f oam ing to dissipate to p e rm it
visual inspection.
IM
Reconstitute wi t h 3.2 m l W FI or 0.5% lignocaine HCl.
Diluent
NS
IV infusion
Adm inister over 15 – 30 minutes. 15
IM
Adm inister by deep IM injection.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Anidulafungin Injection
Reconstituted
Total Infusion
Duration of
Number of
Minimum
Required
Required
Infusion
Infusion
Infusion
VolumeA
VolumeB
Rate of
Volume
Dose
Vials
Total
A
Either 9 m g / m l (0.9%) s odium chloride for infusion or 5 0m g /m l (5%)
glucose for infusion.
B
Infusion solution concentration is 0.77m g/m l.
Diluents
NS, D5
16
IV infusion ONLY
The rate of infusion should n o t exceed 1.1mg/minute (equivalent to
1.4ml/minute or 84m l/hour wh e n reconstituted and diluted per
instructions).
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Artesunate Injection
Further Dilution Dilute the reconstituted solution (1 ml) w i t h diluent to produce the
required concentration.
IV 5m l 6ml 10mg/ml
IM 2m l 3m l 20m g/m l
IM
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Azithromycin Injection
5 1 500
5 2 250
Diluents
NS, D5
References Product leaflet Vaxcel® Azithrom ycin IV For Infusion, (Kotra Pharm a
(M) Sdn. Bhd, Malaysia).
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Brand Nam e Benzapen Sterile Penicillin G Benzathine USP (Strength: 2.4 Mega
Units)
Benzylpenicillin Injection
Continuous IV infusion
Further dilute in 1000 – 2000m l diluent.
Diluent
NS
Adm inistration IM
Alternate sites should be used for repeated injections.
Intermittent IV infusion
■ Adm inister over 1 – 2 hours (adults).
■ Adm inister over 15 to 30 m inutes (children and infants).
20 Continuous IV infusion
■ Adm inister over 24 hours.
■ Preferred for adm inistration of large doses.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
50mg vial
Reconstitute 1 vial (50mg) w i t h 10.5ml of NS or W FI to obtain a
concentration of 5.2mg/ml.
70mg vial
Reconstitute 1 vial (70mg) w i t h 10.5ml of NS or W FI to obtain a
concentration of 7.2mg/ml.
Note:
Paediatric patients (≥ 12 months old): Dilute reconstituted solution
(volume equal to the calculated dose) to an IV bag or bottle containing
250m l of diluent or a reduced volum e of diluent, no t to exceed a final
concentration of 0.5mg/ml.
Diluents
NS or 0.45% Sodium Chloride (Paediatric patients)
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
22
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cefazolin Injection
IM
Reconstitute 1 vial (1 g) wi t h 4 m l 0.5% lidocaine solution.
Diluent
NS
IV infusion
Adm inister doses > 1 g over 20 – 30 minutes.
IM
Inject into a m ajor m uscle mass.
23
Storage & Stability Use im m ediately
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cefepime Injection
Reconstitution IV
Reconstitute 1 vial (1 g) w i t h 10ml of diluent (approximate concentration
90mg/ml).
IM
Reconstitute 1 vial (1 g) w i t h 3m l of diluent (approximate concentration
230mg/ml).
Diluents
WFI, D5, NS
Diluents
D5, NS
24 IV infusion
Adm inister over 30 minutes.
IM
Adm inister t h r ou gh deep IM injection into a large m uscle mass.
References Product leaflet Cefmex Powder For Injection (Duopharm a (M) Sdn. Bhd,
Malaysia). Revised date: 14.10.2014.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cefoperazone Injection
Reconstitution IV
■ Reconstitute 1 vial (1 g) wi t h 5m l of D5, NSD5, NS or WFI.
■ For continuous IV infusion, dissolve each g r a m in 5m l WFI.
IM
W FI m a y be used to prepare cefoperazone for IM injection. However,
w h e n concentrations of ≥250m g / m l to be administered, a lidocaine
solution should be used. A 2-STEP dilution process is recom m ended.
Diluents
D5, NSD5, NS
Intermittent IV infusion
Adm inister over a period of 15 m inutes – 1 hour.
IM
Deep IM injection into t he large m uscle mass of gluteus m a x i m u m or
anterior thigh.
References Product leaflet Bicafar (Duopharm a (M) Sdn Bhd, Malaysia). Revised
date: 14.8.2012.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Reconstitution & IV
Further Dilution
Equiv. Dosage of
Total Volume of Maximum Final
Sulbactam +
Dosage (g) diluent Conc. (mg/ml)
Cefoperazone (g)
1 0.5 + 0.5 3.4 125 + 125
Intermittent IV infusion
Dilute the reconstituted solution to 20m l wi t h the same solution.
IM
Reconstitute 1 vial (1g) with 3.4ml sterile WFI and further dilute with
2% lidocaine to obtain solutions containing u p to 125mg cefoperazone
and 125mg sulbactam/ml in approximately a 0.5% lidocaine
hydrochloride solution.
IM
References Product leaflet Vaxcel® Cefobactam Injection (Kotra Pharm a (M) Sdn.
Bhd, Malaysia).
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cefotaxime Injection
■ Continuous drip
Dilute in 100ml of isotonic saline or glucose solution.
Diluents
NS, D5, D10 (for short infusion)
Short infusion
Infused in approximately 20 minutes.
Continuous drip
Infuse over 50 – 60 minutes.
IM
27
Inject deep into the gluteus muscle. Not to inject >4m l into either side.
If daily dose exceeds 2 g, IV injection is preferred.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Ceftazidime Injection
Brand Nam e Cefatum Injection (Strength: 1 g , 2 g)
Diluents
NS, D5
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Ceftriaxone Injection
Reconstitution IM
■ WFI, NS, D5, 1% lidocaine solution (without ephinephrine)
IV
■ WFI, NS, D5
Vial Dosage Size Amount of Diluent to be
Added
500mg 4.8m l
1g 9.6ml
Diluents
NS, D5
IM
Concentration
Diluent (mg/ml) RT (25○C) Fridge (4○C)
References 1. Product leaflet Unocef Injection (Duopharm a (M) Sdn Bhd, Malaysia).
Revised date: 2.10.2013.
2. Gray, A., W right, J., Goodey, V. and Bruce, L., 2011. Injectable Drugs
Guide. Pharmaceutical Press.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cefuroxime Injection
Reconstitution IM
Reconstitute 750m g vial wi t h 3 m l of WFI.
IV
■ Reconstitute 750m g vial wi t h 8m l of WFI.
■ Reconstitute 1. 5 g vial wi t h 16 m l of WFI.
Diluents
NS, D5
Intermittent IV infusion
Adm inister over 30 minutes.
IM
Inject deep IM into large m uscle mass (such as gluteus or lateral
part of the thigh). 31
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Clindamycin Injection
Brand Nam e Tidact Injection (Strength: 300m g/2m l)
Reconstitution Not required
Further Dilution ■ Must be DILUTED prior to IV administration.
■ To prepare initial dilution for IV use:
Diluents
NS, D5
Adm inistration IV infusion
■ Do n o t adm inister m or e than 1200mg in a single 1 hour infusion.
■ May be adm inistered as a single rapid infusion on the first dose and
followed by continuous IV infusion, as follows:
To Maintain Serum Rapid Infusion Rate Maintenance
Clindamycin Levels Infusion Rate
Above 4 m c g / m l 10 m g / m i n u t e 0.75 m g / m i n u t e
32 for 30 m inutes
Above 5 m c g / m l 15 m g / m i n u t e 1 mg/minute
for 30 m inutes
Above 6 m c g / m l 20 m g / m i n u t e 1. 25 m g / m i n u t e
for 30 m inutes
IM
■ Single IM Injection should n o t exceed 600 m g.
1. Product leaflet Tidact Injection (Yung Shin Pharmaceutical Ind. Co., Ltd,
References Taiwan).
2. Gray, A., W right, J., Goodey, V. and Bruce, L., 2011. Injectable Drugs Guide.
Pharmaceutical Press.
3. Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill
Professional.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Cloxacillin Injection
IM (Use WFI)
250 1. 9 2 125
500 1.7 2 250
IV Injection (Use WFI)
250 4.9 5 50
500 4.8 5 100
IV infusion
Reconstitute 1 vial in 5m l of WFI.
Further Dilution IV infusion
Dilute the reconstituted solution in 125ml to 250m l of diluent to obtain
a final concentration of 1 – 2mg/ml.
Diluent
NS
Adm inistration Slow IV bolus
■ Adm inister into a vein either directly or via a drip-tube over a period 33
of 3 to 4 minutes.
■ More rapid adm inistration m ay result in convulsive seizures.
IV infusion
Infused over 30 to 4 0 minutes.
IM
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Ertapenem Injection
Reconstitution IV infusion
Reconstitute 1 vial (1 g) wi t h 10ml sterile WFI, NS or bacteriostatic WFI.
IM
■ Reconstitute 1 vial (1 g) w i t h 3.2ml of 1% or 2% lidocaine HCl injection
( without epinephrine).
■ The reconstituted solution should n o t be adm inistered intravenously.
Diluent
NS
IM
Adm inister the reconstituted solution by deep IM injection into a large
m uscle mass (e.g. gluteal m uscle or lateral part of the thigh).
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Diluents
NS, D5
Continuous IV infusion
Adm inister the diluted solution over 24 hours.
Storage & Stability The injection should be freshly prepared and unused portion should be
discarded.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Ganciclovir Injection
Diluents
NS, D5
References 1. Product leaflet Cymevene ® (F. Hoffm an-La Rocge Ltd. Basel).
Revised date: June 2010.
2. Gray, A., W right, J., Goodey, V. and Bruce, L., 2011. Injectable Drugs
Guide. Pharmaceutical Press.
3. Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill
Professional.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Gentamicin Injection
Diluents
NS, D5
Adm inistration IM
Slow IV bolus
Adm inister slowly over 2 to 3 minutes.
IV infusion
Adm inister the diluted solution over 20 – 30 minutes.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Diluents
NS, D5
38
Storage & Stability RT (30°C) Fridge (5°C)
After reconstitution 4 hours 24 hours
After dilution 4 hours 24 hours
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Meropenem Injection
Diluents
NS, D5
IV infusion
Adm inister over 15 – 30minutes.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Micafungin Injection
Brand Nam e Mycam ine ® Powder For Solution For Infusion (Strength: 50m g)
Diluents
NS, D5
Adm inistration IV infusion ONLY
■ An existing IV line should be flushed wi t h NS prior to infusion.
■ Administer the reconstituted and diluted solution over approximately
one hour.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer
to the current pr oduc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Netilmicin Injection
Diluents
NS, D5
IV infusion
Adm inister the diluted solution over 1.5 to 2 hours.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Brand Nam e DBL TM Pentam idine Isethionate For Injection (Strength: 300m g)
Diluents
NS, D5
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Diluents
WFI, NS, D5
Diluents
NS, D5
IV infusion
Adm inister over 20 – 30 minutes.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Diluents
D5, NS, D10
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Vancomycin Injection
Brand Nam e Celovan Powder For Solution For Injection/Infusion (Strength: 500m g)
Diluents
NS, D5
Voriconazole Injection
Further Dilution Further dilute the required volum e of reconstituted solution according
to patient’s B W to a final concentration of 0.5 – 5m g/ml.
Diluents
NS, HSD5, D5
References Product leaflet Vfend ® (Pharmacia & Upj ohn Company, USA). Revised
date: April 2014.
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
47
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
Zidovudine Injection
Further Dilution ■ Add and m ix the required dose wi t h diluent to obtain a final
concentration of either 2m g / m l or 4m g/m l.
■ Dilution m u s t be carried o u t under full aseptic conditions.
Diluent
D5
*The inform ation provided in this guideline m ay be used as general reference only. Please refer to
the current produc t inserts for relevant brand used in facility.
APPENDICES
Appendix 1 Glossary
49
Appendix 2 Best practices for injection
Appendix 3 Storage conditions
Appendix 4 Conversions & calculations
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
APPENDIX 1: GLOSSARY
5. Continuous intravenous (IV) The adm inistration of a fluid into a blood vessel,
infusion usually over a prolonged period of time.
6. Interm ittent intravenous (IV) ■ This is the technique used to adm inister an
infusion injectable d r ug in an intravenous infusion over
a period of t i m e ranging f r o m 20 m inutes to
several hours. Repeated doses or single doses
are given in this way.
■ The infusion m ay be connected to the prim ary
intravenous giving set or to a secondary
adm inistration set via a Y-connector.
■ The volum e of intravenous fluid used to dilute
the d r ug ranges f r o m 50m l (the smallest
intravenous fluid bag) u p to 500ml. In clinical
practice m os t drugs are given in 100ml and
are set to infuse over 20-30 minutes.
References:
1. Ministry of Health, Malaysia, 2017. Safe Operating Procedure for Adm inistration of Intravenous
(Bolus), Nursing Division.
2. Gray, A., W right, J., Goodey, V. and Bruce, L., 2011. Injectable Drugs Guide. Pharmaceutical Press.
3. https://www.cancer.gov/publications/dictionaries/cancer -terms/search [online]
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
General Information:
■ All preparations should be done using aseptic technique.
■ Do NOT use the initial concentrate or the infusion solution if there is any sign of precipitation
and presence of foreign m atter in either one.
■ Do NOT m ix other drugs to the infusion solution to avoid any possible d r u g interactions.
■ Any unused portion should be discarded after the rec om m ended period of use.
■ For m ultiple use vials, reconstituted solution m us t be labelled w i t h t i m e and date im m ediatel y
after preparation and m u s t be placed under rec om m ended storage condition.
■ Flush IV line before and after administration. The m os t c o m m o n fluid adm inistered as an IV
flush is s odium chloride 0.9%. In some instances, glucose 5% m ay be used if it is m ore suitable
for use due to com patibility wi t h the IV m edicine being administered.
*This general inform ation m a y n o t be applicable to all the medications stated in this guideline.
Please refer to the pr oduc t inserts or consult your pharm acist for further information.
Do Do Not
DO carry out hand hygiene (use soap and DO NOT forget to clean your hands.
water or alcohol rub), and wash carefully,
including wrists and spaces between the
fingers, for at least 30 seconds.
52
(follow WHO’s ‘My 5 m om ents for hand
hygiene')
DO use one pair of non-sterile gloves per ■ DO NOT use the same pair of gloves for
procedure or patient. m ore than one patient.
■ DO NOT wash gloves for reuse.
Do disinfect the skin at the venepuncture site. DO NOT touch the punc ture site after
disinfecting it.
DO discard the used device (a needle and DO NOT leave an unprotected needle lying
syringe is a single unit) immediately into a outside the sharps container.
robust sharps container.
DO seal the sharps container with a DO NOT overfill or decant a sharps container.
tamper-proof lid.
References:
1. W orld Health Organization, 2010. W HO best practices for injections and related procedures
toolk it (No. WHO/EHT/10.02). W orld Health Organization.
2. Pharmaceutical Services Division, Penang State Health Departm ent, 2016. Antim icrobial
Dilution Protocol.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
The storage conditions for materials and/or products and/or cosmetics should follow the required
storage specification of the materials and/or products and/or cosmetics.
W here tem perature is n o t stated (in term s of range) on the labels of the materials and/or products
and/or cosmetics the following definitions should be followed:
Room tem perature The tem perature is between 15°C and 30°C
Do n o t store over 30°C The tem perature is between 2°C and 30°C 53
Do n o t store over 25°C The tem perature is between 2°C and 25°C
Do n o t store over 15°C The tem perature is between 2°C and 15°C
Do n o t store over 8°C The tem perature is between 2°C and 8°C
Do n o t store below 8°C The tem perature is between 8°C and 25°C
Reference:
Ministry of Health Malaysia, 2nd Edition 2013. Guidelines on Good Distribution Practice (GDP).
D IL U T IO N G U I D E L I N E FOR I N J E C T A B L E D R U G S
1. Metric measures
1 g r a m (g) = 1,000 m g
Concentration of solution in m g / m l = m g of d r u g
m l of solution
Infusion rate in m g / m i n u t e = m g of d r u g
x flow rate (ml/hour) ÷ 60 m inutes
m l of solution
Reference:
Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill Professional.
D I L U T I O N G U I D E L I N E FOR I N J E C T A B L E D R U G S
REFERENCES
[1] Clinical Pharmacy Unit, Pharmacy Departm ent, Hospital Taiping. Hospital Taiping
Antibiotics Dilution & Adm inistration Protocol . (1st ed.). Ministry Of Health Malaysia.
[2] Dilution Protocol 2017 Hospital Tuanku Am p ua n Najihah, Kuala Pilah. Ministry Of
Health Malaysia.
[3] Gray, A., W right, J., Goodey, V. and Bruce, L., 2011. Injectable Drugs Guide.
Pharmaceutical Press.
[4] Mimsgateway.com. 2020. Mim s Gateway > Malaysia > Overview. [online] Available at:
<http://www.mimsgateway.com/malaysia/overview>.
[5] Ministry of Health Malaysia, 2nd Edition 2013. Guidelines on Good Distribution
Practice (GDP).
[6] Ministry of Health, Malaysia, 2017. Safe Operating Procedure for Administration of
Intravenous (Bolus), Nursing Division.
[7] Ojerinde, A. and Adejumo, P., 2014. Factors Associated W i t h Medication Errors
A m o n g Health W orkers In University College Hospital, Nigeria. IOSR Journal of
Nursing and Health Science, 3(3),pp.22-33.
[8] Pharmaceutical Services Division, Penang State Health Departm ent, 2016.
Antim icrobial Dilution Protocol.
55
[9] Pharmacy.gov.my. 2020. Formulari Ubat KKM (FUKKM) | Pharmaceutical Services
Programme. [online] Available at: <https://www.pharmacy.gov.my/v2/en/apps/fukkm>.
[10] Schull, P.D., 2009. McGraw-Hill’s IV Drug Handbook. McGraw Hill Professional.
[11] Selangor State Health Depa r tm ent (2017). Dilution Protocol . (1st ed.). Ministry Of
Health Malaysia.
[12] W orld Health Organization, 2010. W HO best practices for injections and related
procedures toolk it (No. WHO/EHT/10.02). W orld Health Organization.
NOTE:
Pharm aceutical Services P r o g r a m m e
Ministry of Health Malaysia
Lot 36, Jalan Universiti
46200 Petaling Jaya
Selangor Darul Ehsan
Tel : 03-78413200
Fax : 03-79682222
www.pharmacy.gov.my