CHHS16/010

Canberra Hospital and Health ServicesMedication Guideline Nebulised Pentamidine - Administration Contents

Contents....................................................................................................................................1

Introduction..............................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Patient suitability for nebulised pentamidine.........................................................2

Section 2 – Risks to staff and patients associated with nebulised pentamidine.......................3

Section 3 – Personal protective equipment..............................................................................4

Section 4 – Administration of nebulised pentamidine..............................................................4

Implementation........................................................................................................................ 6

Related Legislation, Policies and Standards..............................................................................6

References................................................................................................................................ 6

Definition of Terms...................................................................................................................7

Search Terms............................................................................................................................ 7

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Introduction

This guideline outlines the processes for the use of nebuliser therapy to administer pentamidine at Canberra Hospital and Health Services (CHHS).

Pentamidine is an antiprotozoal agent used for the prophylaxis of Pneumocystis jiroveci pneumonia (PJP) in immunocompromised patients.

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Alerts

1. A negative pressure room is required for patients who have active TB. For all other patients, a negative pressure room is the preferred setting. When a negative pressure room is not available, and the patient does not have active TB, nebulised pentamidine may be administered in a well ventilated clinic room, with an extractor fan.

2. Where possible the staff member should not be present in the room during nebulisation. The staff member should return for frequent, brief checks on the patient. If required to remain with the patient for longer periods, staff member must wear a P2 or N95 respirator mask.

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Scope

This document is applicable to all clinicians who provide a service to a patient at the CHHS: All Medical Officers All nurses who are working within their scope of practice (Refer to: Nursing and

Midwifery Continuing Competence Policy)

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Section 1 – Patient suitability for nebulised pentamidine

Pentamidine has proven efficacy against PJP but is inferior to sulfamethoxazole/ trimethoprim.

Nebulised pentamidine is recommended for immunocompromised patients withsignificant sulphonamide allergy or significant side effects to sulfamethoxazole/ trimethoprim such as severe myelosuppression, and where other alternative agents such as dapsone are unsuitable.

Immunocompromised patients for whom nebulised pentamidine is indicated, and recommended duration of therapy, include:

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patients with HIV infections (including children that may be affected by vertical transmission) until CD4+ count is >200 cells/microl

patients with other conditions increasing susceptibility to PJP including:o patients with Acute Lymphoblastic Leukaemia (throughout therapy)o patients post allogenic stem cell transplantation (although IV preparations are

preferred in terms of efficacy – see below *) for at least 6 months and while on immunosuppressant therapy

o patients post autologous stem cell transplantation; for 6 months o patients receiving fludarabine and/or other T cell depleting agents for at least 6

months or until CD4+ count is >200 cells/microL, whichever occurs firsto patients with Hodgkin lymphoma whilst on therapyo patients with non-Hodgkin lymphoma whilst on therapyo patients receiving high dose methotrexate regimens (≥1g/m2) whilst on therapyo patients on corticosteroid therapy (in those receiving the equivalent of a minimum

of prednisolone 20mg daily for more than a month) in combination with other immunosuppressant therapy; cease 2 weeks after cessation of steroids

o patients post solid organ transplant.

*IV pentamidine is preferred as prophylaxis for PJP in patients post allogeneic stem cell transplantation at a dose of 4mg/kg IV every 2-3 weeks.

Note: IV pentamidine is also used therapeutically for suspected or proven PJP as 4mg/kg IV daily therapy for 14-21 days.

All patients requiring nebulised pentamidine therapy should be advised to stop smoking. Individuals who smoke have an increased risk of PJP and may have a more complicated treatment course.

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Section 2 – Risks to staff and patients associated with nebulised pentamidine

Bronchoconstriction due to escape of nebulised particles o Staff and patients with a history of asthma or who are smokers have an increased

likelihood of bronchospasm Transmission of tuberculosis from patients with active TB. As the effect of inhaled pentamidine is unknown in human pregnancy, staff who are

pregnant should avoid handling pentamidine.

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Section 3 – Personal protective equipment

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P2 or N95 maskAll clinicians involved in the administration of inhaled pentamidine must wear a P2 or N95 mask to protect against bronchoconstriction and other adverse effects of pentamidine to protect against the possible transmission of respiratory pathogens.

In addition, it is important that all staff practice Standard Precautions as follows: Perform hand hygiene before and after patient contact using the 5 moments of hand

hygiene. Use protective barriers, which may include gloves, gowns, plastic aprons, masks, eye

shields or goggles as well as P2 or N95 mask as above. Ensure appropriate handling and disposal of sharps and other contaminated or

infectious waste, and linen. Utilise aseptic techniques. Utilise appropriate antiseptics/disinfectants.

Additional Precautions are used for patients who are known or suspected to be infected or colonised with important or highly transmissible pathogens. They must be used in conjunction with Standard Precautions and include: Contact precautions

o direct with patient/person contacto indirect contact (i.e. contact with contaminated surface or equipment)

Droplet precautions Airborne precautions.

For specific information on additional Precautions and PPE please refer to the CHHS Healthcare Associated Infections Procedure.

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Section 4 – Administration of nebulised pentamidine

Equipment Optimist Plus disposable nebuliser (for salbutamol) Angled mouth piece, system 22 Salbutamol 2.5mg in 2.5mL nebule Sodium chloride 0.9% ampoule Oxygen cylinder or wall oxygen Respirgard 11® nebuliser pack (for pentamidine) Pentamidine isethionate 300mg vial Sterile water for injection ampoule Call bell Recliner chair Bottle/glass of water Door sign “Do Not Enter”

Procedure

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1. Staff are to perform hand hygiene according to the 5 moments of hand hygiene as set out by Hand Hygiene Australia

2. All Canberra Hospital patients receiving pentamidine must be accompanied by their medication chart, observation chart and notes

3. Check medication order and collect required medications and equipment4. Don Personal Protective Equipment (including P2 or N95 mask) if needed prior to any

patient contact as per Additional Precautions (Section 3) 5. Explain the procedure to the patient, including the medications, equipment and possible

side effects and obtain verbal consent 6. Record baseline blood pressure, pulse and respiration rate. Seek medical review with

concerns 7. Don P2 or N95 mask if not already being used and assist the patient to a sitting or semi-

recumbent position8. Place salbutamol 2.5mg into the Optimist Plus disposable nebuliser, add sodium chloride

0.9% to make up to required volume of 4mL, then add mouthpiece9. Attach the oxygen tubing to cylinder or to wall oxygen and adjust the flow rate (no less

than 6L/minute) to achieve a fine mist10. Instruct the patient to close the lips firmly around the mouthpiece and to inhale through

the mouth and exhale through the nose, and to breathe deeply and slowly11. When salbutamol inhalation is completed, discard the Optimist Plus nebuliser12. Wait 10 minutes before commencing pentamidine 13. Explain that a staff member will be available but will not stay in the room during

pentamidine treatment; keep the door closed with a visible “Do Not Enter” sign on the door

14. Ensure the patient can access and use the call bell, and ask them to call if they require assistance

15. Instruct patient to use nebuliser (as above), how to turn off the oxygen flow if they need to take a break during the pentamidine nebuliser treatment, and how to recommence the nebulise

16. Ask the patient to recline their chair after the first 10 mins of treatment (being careful not to spill the liquid in the nebuliser) and continue treatment in this position for a further 10 minutes, breathing as above. This change in position helps distribute pentamidine through the lungs. After 10 minutes in the reclined position, the patient should return the chair to the upright position for the remainder of the treatment.

17. Ensure a bottle/glass of water is within patient reach18. Dissolve pentamidine 300mg in 6mL of sterile water for injection and shake well19. Place diluted pentamidine into nebuliser included in the Respirgard 11® nebuliser pack20. Commence nebulised pentamidine at an oxygen flow rate of 6L/minute21. Check patient intermittently for side effects of pentamidine:

a) Bronchospasm – stop nebuliser and seek urgent MO reviewb) Excessive cough – ensure oxygen flow rate <10L/min, reduce inspiration ratec) Dizziness – monitor blood pressure, reduce deep breathing

22. When nebulisation of pentamidine is complete discard Respirgard 11® nebuliser equipment in clinical waste bin

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23. Record post nebuliser blood pressure, pulse and respiration rate. Seek medical review with concerns

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Implementation

In-service and multidisciplinary education; Placed on notice boards in tea rooms; and Distributed to staff via email.

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Related Legislation, Policies and Standards

Related Legislation and Policies (including but not limited to) CHHS Medication Handling Policy ACT Health Waste Management Policy CHSS Healthcare Associated Infections Procedure Nursing and Midwifery Continuing Competence Policy

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References

Nebulisers in eTherapeutic Guidelines (2013). Retrieved 2 September 2013 from http://online.tg.org.au/ip/

Post, J. (2009) Pneumocystis jirovecii pneumonia in HIV Management in Australasia – a guide to clinical care. Australasian Society for HIV Medicine, Sydney.

Vasconcelles MJ, Bernardo MV, King C, Weller EA, Antin JH. Aerosolized pentamidine as pneumocystis prophylaxis after bone marrow transplantation is inferior to other regimens and is associated with decreased survival and an increased risk of other infections. Biol Blood Marrow Transplant. 2000;6(1):35-43.

Miguez-Burbano MJ, Ashkin D, Rodriguez A, et al. Increased risk of Pneumocystis carinii and community-acquired pneumonia with tobacco use in HIV disease. Int J Infect Dis. Jul 2005;9(4):208-17)

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Definition of Terms

PJP - Pneumocystis jiroveci pneumonia

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Search Terms

Pentamidine, Antiprotozoal, Pneumocystis jiroveci pneumonia (PJP), Nebuliser, Aerosolised

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Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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