In the study reported here, almost 70% of respondents’ institutions had changed their policies with respect to administration of ceftriaxone in response to the warnings. Conversely, only 14.7% of respondents indicated that their institutions considered the coadministration of ceftriaxone and calcium- containing IV solutions to be an absolute contraindication. This may indicate that the impact of the Health Canada Notice to Hospitals on actual practice has been limited.
The limitations of this study should be considered in the interpretation of the results. The survey tool has not been validated and was intended for exploratory analysis. For the sake of timeliness, the questions were developed and the survey conducted within a relatively short period of time. The survey was intentionally brief to ensure the highest possible response rate, but this brevity came at the cost of not fully exploring the reasoning behind respondents’ opinions. The sample size was relatively small, and the possibility of selection bias is inherent to the method used to solicit participation. We did not receive confirmation from all PSNs that participation in the survey had been solicited. Unfortunately, it was not possible to accurately determine the survey response rate, because individual respondents might have belonged to more than one PSN, and information about such overlap was not available. Limiting participation in the survey to practitioners belonging to one or more of the CSHP PSNs may have led to selection of a subset of practitioners who were most strongly affected by this issue. Also, the survey responses were from individual pharmacists, not institutions, which limited the ability to fully assess institutional responses to the warnings. The survey was conducted in English only, which may have limited responses from Quebec.
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Despite strongly worded warnings issued by the manufacturer and Health Canada, only a small percentage of institutions represented by participants in this survey had changed their ceftriaxone administration polices to comprehensively reflect the warnings. Furthermore, the study results signify that the warnings are impractical and may not reflect the true risk among adults. Until more evidence for adults is available, a more reasonable warning might be that, in situations in which the benefit outweighs the risk, ceftriaxone may be used for patients receiving calcium-containing IV solutions, but only on a case-by-case basis, with careful clinical assessment performed each time the drug is administered.
There is disagreement within the hospital pharmacy community with regard to the strict interpretation of the 2008 Health Canada Notice to Hospitals about concomitant use of ceftriaxone and calcium-containing IV solutions. A large proportion of hospital pharmacy practitioners responding to this survey were concerned by recent warnings but did not agree with strict adherence to the recommendations issued by Health Canada, specifically as they pertained to a 48-h calcium avoidance window for non-neonatal patients. Viagra Professional
Note Added at Time of Publication
The survey reported here was conducted to capture the opinions of Canadian hospital pharmacists about an important clinical issue as the situation was unfolding. On October 15, 2009, Health Canada issued a Notice to Hospitals regarding updated prescribing information for all ceftriaxone products marketed in Canada. This notice was based on 2 recent in vitro studies that showed an increased risk of ceftriaxone—calcium precipitates in neonatal plasma. Of note, new recommendations to replace those issued on July 31, 2008, specify that for patients other than neonates, ceftriaxone and calcium- containing solutions may be administered sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid. However, diluents containing calcium, such as Ringer’s solution or Hartmann’s solution, are not to be used to reconstitute vials of ceftriaxone or to further dilute a reconstituted vial intended for IV administration. Furthermore, ceftriaxone must not be administered simultaneously with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition via a Y-site. Of note, mention of a 48-h calcium avoidance window has been removed.