Adult outpatient parenteral antimicrobial therapy (OPAT) good practice prescribing guide

Piperacillin/tazobactam 24 hour continuous infusion via elastomeric infusion device

Piperacillin/tazobactam is a penicillin and beta-lactamase combination with broad spectrum activity against Gram-positive and Gram-negative bacteria.  It is licensed for severe pneumonia (including hospital and ventilator associated), intra-abdominal infections, complicated urinary tract infections, complicated skin and soft tissue infections (including diabetic foot infections), bacteraemia associated with these indications and bacterial infections associated with neutropenic sepsis and fever.

This guide shares practical experience on the use of piperacillin/tazobactam in an OPAT setting. To create the guidance, we took an evidence based approach. We also used expert consensus and practical experience from across NHS Scotland.

This drug summary does not provide specific treatment guidelines. Individual patient treatment should take into account the core principles of antimicrobial stewardship. This includes selection of the appropriate antimicrobial for the shortest duration with oral therapy being preferred, whenever possible.

For information on Route and method of administration, Contraindications, Cautions and adverse effects and Drug interactions please refer to the following approved resources:

These resources also have more information on licensed indication, use in pregnancy and use in breast feeding. When using unlicensed medicines, and/or off-label doses or indications, follow local health board governance processes.   

The use of broad spectrum antibiotics is associated with an increased risk of Clostridioides difficile infection (CDI).  Please monitor patient for new loose stools.  If suspicion of CDI send stool sample to microbiology for analysis.

It is strongly recommended that OPAT services in Scotland adhere to the Key performance indicators for the management of patients in an outpatient parenteral antimicrobial therapy (OPAT) setting.

Piperacillin/tazobactam 24 hour continuous infusion via elastomeric infusion device

​1. Indication and dose

Please note that whilst piperacillin/tazobactam and the elastomeric infusion devices are licensed in the UK, following the compounding process the drug and device combination is referred to as an unlicensed product.

Off-label indications in the OPAT setting Type of Dose Dosing Considerations
Deep seated infections where Pseudomonas sp isolated or suspected eg malignant otitis externa, bone and joint infection, diabetic foot infection and bronchiectasis Loading dose Patient has NOT received piperacillin/tazobactam within the previous 6 hours Give loading dose 4.5g as IV infusion over 30 minutes
Patient has received piperacillin/tazobactam within the previous 6 hours No loading dose required.  The maintenance dose can be started immediately
Maintenance dose Creatinine Clearance (CrCl) over 40ml/min
18g as IV continuous infusion via elastomeric infusion over 24 hours

CrCl 40 ml/min or less
See dose table (section ‘Dose adjustments’) below
  • Start the maintenance dose immediately after the end of the loading dose infusion or within 6 hours of a previous piperacillin/tazobactam dose
  • Replace the elastomeric infusion device at the same time every 24 hours
Complicated intra-abdominal infections and
Complicated skin and soft tissue infections (including diabetic foot infection) where Pseudomonas sp are NOT isolated or suspected		 Loading dose Patient has NOT received piperacillin/tazobactam within the previous 8 hours Give loading dose 4.5g as IV infusion over 30 minutes
Patient has received piperacillin/tazobactam within the previous 8 hours No loading dose required.  The maintenance dose can be started immediately
Maintenance dose CrCl 20 ml/min or more
13.5g as IV continuous infusion via elastomeric infusion over 24 hours

CrCl less than 20 ml/min
See dose table (section ‘Dose adjustments’) below

  • Start the maintenance dose immediately after the end of the loading dose infusion or within 8 hours of a previous piperacillin/tazobactam dose
  • Replace the elastomeric infusion device at the same time every 24 hours
  


Additional information

  • Piperacillin/tazobactam (18g/ 13.5g/ 9g) pre-filled elastomeric infusion devices may be purchased from a private UK pharmaceutical compounding provider or prepared by NHS Scotland aseptic services.
    • It can take several working days to obtain stock if purchased from a private UK pharmaceutical compounding provider.
  • When initiating patients on continuous infusion delivery devices consider the feasibility and timing of pump exchange in relation to previous inpatient dosing and/ or loading doses to ensure optimal therapy.
  • The elastomeric infusion devices must be kept in the fridge. Ensure patient has a working fridge to store infusion devices prior to use.
  • Ensure patient/ care representative are appropriately trained to administer the elastomeric infusion devices as per local OPAT service standard operating procedures and are provided with appropriate patient information resources.
  • The elastomeric infusion devices should be attached, and the contents administered via a peripherally inserted central catheter (PICC) line. A single lumen PICC, size 4 French gauge is recommended.
  • This paper has additional information on stability: Jamieson C et al. Assessment of the stability of citrate- buffered piperacillin/tazobactam for continuous infusion when stored in two commercially available elastomeric devices for outpatient parenteral antimicrobial chemotherapy: a study compliant with the NHS Yellow Cover Document requirements. European Journal of Hospital Pharmacists, 2020.  Available at: https://ejhp.bmj.com/content/ejhpharm/early/2020/09/24/ejhpharm-2020-002340.full.pdf

2. Dose adjustments

2a. Renal impairment
Renal function must be stable prior to decision to using these infusion devices.

Loading dose: ALL patients require a loading dose (see section ‘Indication and dose’)

Maintenance dose: 

Renal function
Creatinine Clearance (CrCl)		 Dosage adjustment
20–40ml/min 13.5g administered over 24 hours as a continuous IV infusion via elastomeric infusion device
Less than 20ml/min 9g administered 24 hours as a continuous IV infusion via elastomeric infusion device
Haemodialysis
If receiving regular three times a week haemodialysis (eg Mon/Wed/Fri): 
OR
Continuous Ambulatory Peritoneal Dialysis (CAPD)		 9g administered 24 hours as a continuous IV infusion via elastomeric infusion device
Haemodialysis (irregular frequency) Not recommended


2b. Other dosage adjustments

Patient characteristic Dose advice
Hepatic impairment No dose adjustment necessary
Obesity No dose adjustment necessary
Rescue “top up” doses (for all indications)

At 24 hours if the elastomeric infusion device has not sufficiently emptied (60 ml or more or 25 % remains in elastomeric device) then consider a one-off ‘top up’ dose.

All patients MUST be discussed with the OPAT team before a ‘top up’ dose is given

  • The patient or care representative should clamp the peripherally inserted central catheter (PICC) line, remove the old elastomeric infusion device, place a cap on the device to prevent any leakage and attend the OPAT service or designated out of hours service (with the elastomeric infusion device) for further treatment and advice.
  • Assessment of the elastomeric infusion device and PICC line must be performed.
  • If this occurs on more than 3 consecutive occasions the patient may require an alternative antimicrobial treatment plan or need to be readmitted to hospital.


3. Monitoring requirements

Frequency Recommended monitoring
Baseline
  • Urea and Electrolytes (U&Es), liver function tests (LFTs), C-reactive protein (CRP) and full blood count (FBC).
  • If the patient or care representative are attaching the new pumps rather than an OPAT or district nurse team they must be trained and observed using the Elastomeric Infusion Devices appropriately.
Next working day If the patient or care representative are attaching the new pumps themselves they must be reviewed by the OPAT service or district nurse team on the next working day to ensure the elastomeric infusion devices are being used appropriately.  The private UK pharmaceutical compounding providers may supply a visual aid to guide elastomeric infusion device emptying. (See section ‘Indication and dose’).
Weekly monitoring
(Note this may be more frequent if clinically necessary)		 U&Es, LFTs, CRP and FBC
Therapeutic drug monitoring No therapeutic drug monitoring required.
Follow up Ensure follow up arranged with referring speciality and/or completed with an infection specialist.


For the use of other antibiotics in an OPAT setting please refer to the SAPG website


 Scottish Antimicrobial Prescribing Group (SAPG) | June 2024 for review June 2027

Content updated: July 2024