April 30, 2011: Mix–ups Continue between Conventional Amphotericin B and Lipid–Based Amphotericin B
Amphotericin B, a systemic antifungal medication, is not commonly used, and health care practitioners may be unfamiliar with its various formulations and the potential consequences of mix–ups among them. The standard dosing for conventional amphotericin B (brand name Fungizone) is substantially lower than those for the lipid–based formulations (AmBisome, a liposomal formulation, and Abelcet, a lipid complex formulation). The dosage of conventional amphotericin B (Fungizone) should never exceed 1.5 mg/kg daily. Higher doses can result in potentially fatal cardiac or respiratory arrest.An article recently published on this topic in Dynamics, the Journal of the Canadian Association of Critical Care Nurses (entitled “ALERT: Mix–ups between conventional and lipid formulations of amphotericin B can be extremely dangerous”) provides an overview of incidents involving amphotericin B that have been reported to ISMP Canada. The article includes a description of a recently reported mix–up between the lipid complex formulation amphotericin B (Abelcet) and the conventional amphotericin B formulation (Fungizone), along with suggested strategies to prevent recurrence. This article is available from www.ismp-canada.org/publications.htm
ISMP Canada thanks the Canadian Association of Critical Care Nurses (www.caccn.ca) for granting permission to share this and other medication safety information with the healthcare community through its Dynamics journal.
