This document alerts all healthcare staff involved in the use of intravenous amphotericin to the potentially lethal results if non-lipid and lipid formulations of the drug are confused. The different formulations are used for the treatment of systemic fungal infections.
Intravenous amphotericin is available in four different formulations: non-lipid deoxycholate complex (Fungizone®) and as lipid formulations (Abelcet®, AmBisome®, and Amphocil®).The dosage recommendations for these preparations range from 1–5mg/kg.
Confusion between the different formulations of amphotericin products can lead to over- or under-dosing due to the different dose recommendations for each product; and patients experiencing potentially lethal side effects or sub-therapeutic doses.
Chief pharmacists, pharmaceutical advisers and heads of pharmacy and medicines management in healthcare organisations should ensure that medical, nursing and pharmacy staff involved in the prescribing, preparation, supply and administration of amphotericin are aware of the potential risks. They should also undertake an immediate risk assessment of amphotericin products and procedures in accordance with NPSA’s Patient Safety Alert 20, ‘Promoting safer use of injectable medicines’, and take action to reduce the risks.
This document is accompanied by supplementary information containing a breakdown of incidents reported to the NPSA and technical information about different formulations of injectable amphotericin.
