ESCRS Guidelines on prevention, investigation and management of

How To Make Up The Antibiotics
The antibiotics should be supplied freshly diluted by the hospital pharmacy department. However, for
emergency cases, a method for diluting the drugs in the operating theatre is given below. The procedure
must use sterile equipment and be undertaken on a sterile surface; ideally, the hospital makes up sterile
packs with drugs, bottles for dilution and instructions in advance for this purpose. All drugs should be mixed
by inverting or rolling the bottle 25 times, avoiding frothing.
Some important “dos” and “don’ts” are:
■ Never return diluted drugs to the same or original vial for further dilution
■ Never dilute at greater than 1 in 10
■ Do not use syringes more than once
■ Do not reuse bottles
■ Avoid use of drugs with preservatives if possible
■ Do inject the drugs slowly over 1 to 2 minutes
Prior to preparing the dilutions it is mandatory to check the amount of the antibiotic in the vial as the same
antibiotic may be sold in different strengths in each EU country.
Vancomycin Dose for use = 1000µg. Reconstitute one vial of 250mg and make up to 10ml with sterile
normal (0.9 per cent) saline (SNS) in a sterile bottle with lid. Mix well. Withdraw 2ml accurately and add to
3ml of SNS in a sterile bottle with lid. Mix well (= 10mg/ml). Use 0.1ml = 1000µg.
Ceftazidime (or other cephalosporin) Dose for use = 2000µg. Reconstitute one vial of 500mg and make up
to 10ml with SNS in a sterile bottle with lid. Mix well. Withdraw 2ml accurately and add to 3ml of SNS in a
sterile bottle with lid. Mix well (= 20mg/ml). Use 0.1ml = 2000µg.
Note: the percentage of drug precipitation is less when using SNS instead of BSS [32].
Amikacin Dose for use = 400µg. Reconstitute one vial of 500mg and make up to 10ml with SNS or
balanced salt solution (BSS) in a sterile bottle with lid. Mix well. Withdraw 0.8ml, using a 1ml syringe, and
add to 9.2ml of SNS or BSS in a sterile bottle with lid. Mix well (= 4.0mg/ml). Use 0.1ml = 400µg.
Gentamicin Dose for use = 200µg. Method 1: Use a 'Minim' which contains 3000µg/ml. Dilute to
2000µg/ml by adding 2ml of the Minim formulation to 1ml SNS in a sterile bottle with lid. Mix well. Use
0.1ml = 200µg for injection. Method 2: Remove 0.5ml, using a 1ml syringe, from a vial containing
40mg/ml unpreserved gentamicin and place in a sterile bottle with lid. Add 9.5ml of SNS or BSS and mix
well (= 2.0mg/ml). Use 0.1ml = 200µg.
Clindamycin Dose for use = 1000µg. Transfer the contents of a 2ml ampule containing 300mg to a sterile
bottle and add 1ml SNS or BSS, replace lid, and mix well. Withdraw 1ml, using a 1ml syringe, and add to
9ml of SNS or BSS in a sterile bottle with lid. Mix well (=10mg/ml). Use 0.1ml = 1000µg.
Amphotericin Dose for use = 5µg. Reconstitute a 50mg vial with 10ml water for injection. Withdraw 1ml,
using a 1ml syringe, and add to 9ml of water in a sterile bottle with lid for injection. Mix well. Withdraw 1ml
of this dilution, using a 1ml syringe, and add to 9ml of dextrose five per cent in a sterile bottle with lid, to
complete a dilution of 1/100. Mix well (= 50µg/ml). Use 0.1ml = 5µg. (A dose of 10µg has been used by
some clinicians.)
Miconazole Dose for use = 10µg. Withdraw 1ml, using a 1ml syringe, from an ampule of intravenous
miconazole containing 10mg/ml and add to 9ml SNS or BSS in a sterile bottle with lid. Mix well. Withdraw
1ml, using a 1ml syringe, and add to 9ml SNS or BSS in a sterile bottle with lid. Mix well (= 100µg/ml).
Use 0.1ml = 10µg.
Within Europe, various manufacturers produce sterile bottles of saline of different volumes for injection with
side-ports, but many are not sold universally. For example in Spain and Portugal, the following method can
be used with Braun's 50ml bottles of saline, suitable for drug dilution with two rubber injection ports [159]:
Vancomycin - mix vial of 500mg with 5ml saline withdrawn from Braun 50ml bottle, shake well and then
return to Braun bottle. Dilution gives 10mg/ml (dose of 0.1ml contains 1mg).
Ceftazidime - mix vial of 1g (1000mg) with 5ml saline withdrawn from Braun 50ml bottle, shake well and
then return to Braun bottle. Dilution gives 20mg/ml (dose of 0.1ml contains 2mg).
Amikacin - add 2ml saline to vial of 500mg. Shake well and remove 0.8ml (= 200mg) to Braun 50ml bottle
and shake well. Dilution gives 4 mg/ml (dose of 0.1ml contains 400µg).
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