November 18, 2015: Errors Continue with Amphotericin B - Ontario Critical Incident Learning Bulletin
Amphotericin B is an antimicrobial drug used in the treatment of severe fungal infections. It is available in 3 formulations for intravenous use in Canada: "conventional" amphotericin B (Fungizone), amphotericin B lipid complex (Abelcet), and liposomal amphotericin B (AmBisome). Lipid-based forms of the drug appear to have less severe toxic effects, but the conventional form of the drug is still available, and many Ontario hospitals reportedly stock multiple formulations. ISMP Canada and ISMP (US) have published several bulletins and alerts on concerns about the risks of inadvertently substituting one formulation for another. Inadvertent substitution of conventional amphotericin B for the liposomal or lipid complex dose will result in an overdose of the active drug, potentially leading to severe toxic effects, such as cardiac and cardiorespiratory arrest. Conversely, substituting the liposomal or lipid complex formulation for conventional amphotericin B could lead to treatment failure through under-dosing of the active ingredient.
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