Last reviewed April 2024
Last reviewed April 2024
Last reviewed April 2024
Maintenance Dose |
|
---|
CrCl (mL/min) | Dosing Interval |
---|---|
Greater than 60 | Q12h* |
30-59 | Q24h |
Less than 30 | Q48h |
Peritoneal dialysis | Q3-7 days** |
Hemodialysis | Usually dosed after each dialysis, consult pharmacist and dialysis order sets. |
*If targeting a higher trough, near 15 mg/L, and patient’s creatinine clearance is greater than or equal to 90mL/min and less than 60 years old, may use 15mg/kg q8h for critically ill patients
**For most patients based on serum monitoring
THERAPEUTIC DRUG MONITORING (TDM)
Trough Target
Endocarditis: |
|
Invasive infections: CNS infections, osteomyelitis, pneumonia, and other deep seated MRSA infections |
Suggest target trough concentrations in higher range, around 15 mg/L |
Trough Monitoring
Other Monitoring
Last reviewed April 2024
1. SHS-UHN Antimicrobial Stewardship Program: https://www.antimicrobialstewardship.com/antimicrobials
2. Sunnybrook Guidelines: https://sunnybrook.ca/glossary/item.asp?i=1164&p=1341&page=
3. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2020;77(11):835-864.
4. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association [published correction appears in Circulation. 2015 Oct 27;132(17):e215] [published correction appears in Circulation. 2016 Aug 23;134(8):e113] [published correction appears in Circulation. 2018 Jul 31;138(5):e78-e79]. Circulation. 2015;132(15):1435-1486.
5. Stewart JJ, Jorgensen SCJ, Dresser L, et al. A Canadian Perspective on the Revised 2020 ASHP/IDSA/PIDS/SIDP Guidelines for Vancomycin AUC Based Therapeutic Drug Monitoring for Serious MRSA Infections. JAMMI. 2021; 6(1):3-9
6. Claeys, KC, Brade, KD, Pro, ELH, Jorgensen, SC, Dresser, LD, & Con, BRD (2020). Should Therapeutic Monitoring of Vancomycin Based on Area under the Curve Become Standard Practice for Patients with Confirmed or Suspected Methicillin-Resistant Staphylococcus aureus Infection? [published correction appears in Can J Hosp Pharm. 2020 Fall;73(4):298]. Can J Hosp Pharm. 2020;73(3):232-237.
Last reviewed April 2024
Tobramycin, gentamicin (agent of choice for Gram-positive synergy), amikacin
Last reviewed Jan 2023
Last reviewed Jan 2023
Risk factors for toxicity: more than 3 days of therapy, renal insufficiency, elevated trough levels, elderly, volume depletion, concomitant nephrotoxic or ototoxic drugs (i.e. amphotericin B, cisplatin), pre-existing hearing/vestibular disorder, prior aminoglycoside exposure (within 3 months).
Last reviewed Jan 2023
*Note: cystic fibrosis patients often require higher dosing regimens; consult with CF team
Last reviewed Jan 2023
Step 1. Calculate dosing rate
Non- obese: Dose based on actual body weight | |
Obese: if body weight is 30% above ideal body weight (IBW), calculate Dosing Weight | |
Dosing Weight: IBW + 0.4 x (actual body weight - IBW) | |
Ideal body weight (IBW) equation:
|
Step 2. Calculate maintenance dose
Use dosing weight:
Step 3. Choose dosing interval based on creatinine clearance
Creatinine Clearance (mL/min) | Dosing Interval |
---|---|
Greater than 60 | q24h |
40-59 | q36h |
20-39 | q48h |
Less than 20 | Avoid once daily dosing |
Step 4. Therapeutic drug monitoring
Drug | Target Trough |
---|---|
Tobramycin/Gentamicin | Less than 1 mg/L |
Amikacin | Less than 2.5 mg/L |
*If initial trough level on target and renal function stable (i.e., not expecting drug accumulation or toxicity), may draw future troughs 30 minutes prior to dose for practicality
Serum creatinine 2 or more times per week; daily clinical assessment of acute changes to hearing or balance/dizzines; audiogram as necessary.
Last reviewed Jan 2023
Step 1. Calculate dosing weight
Non-Obese: Dose based on actual body weight | |
Obese: if body weight is 30% above ideal body weight (IBW), calculate Dosing Weight | |
Dosing Weight: IBW + 0.4 x (actual body weight - IBW) | |
Ideal body weight (IBW) equation:
|
Step 2. Calculate and give loading dose
Use dosing weight:
Step 3. Calculate maintenance dose and choose dosing interval based on creatinine clearance (CrCl)
Tobramycin/gentamicin: 1.7 mg/kg (round to nearest 20mg) |
Amikacin: 5 mg/kg (round to nearest 50mg) | ||
CrCl (mL/min) | Dosing Interval | CrCl (mL/min) | Dosing Interval |
Greater than or equal to 60 | q8h | Greater than or equal to 40 | q12h |
40-59 | q12h | Less than 40 | q24h |
20-39 | q24h | HD | After each HD |
Less than 20* | Once, then based on levels | CRRT | q24-48h |
HD | After each HD | ||
CRRT | q24-48h* |
*Give one dose, check level in 24h, re-dose when level less than 2 mg/L
Step 4. Therapeutic drug monitoring
Indication | Tobramycin/Gentamicin | Amikacin | |
---|---|---|---|
Desired Peak* | UTIs | 3-5 mg/L | 16-20 mg/L |
Serious Infections | 5-10 mg/L | 20-25 mg/L | |
Desired Trough | Less than 2 mg/L | Less than 8 mg/L |
*Target peak may need to be in excess of 10 mg/L (greater than 25mg/L for amikacin) for patients with severe Gram-negative infections
Other Monitoring:
Last reviewed Jan 2023
^ or use previous known dose if no change in weight or kidney function
*After the end of the infusion
Obese Dosing
Consult CF team or pharmacy for dose adjustments
Last updated January 2023
Ensure gentamicin synergy susceptible by high-level aminoglycoside resistance testing (HLAR)
Step 1. Calculate dosing rate
Non- obese: Dose based on actual body weight | |
Obese: if body weight is 30% above ideal body weight (IBW), calculate Dosing Weight | |
Dosing Weight: IBW + 0.4 x (actual body weight - IBW) | |
Ideal body weight (IBW) equation:
|
Step 2. Calculate maintenance dose
Use dosing weight:
Step 3. Choose dosing interval based on creatinine clearance
Creatinine Clearance (mL/min) | Dosing Interval |
---|---|
Greater than 60 | q8h |
40-59 | q12h |
20-39 | q24h |
Less than 20 | Once, then based on levels |
HD | After each HD |
CRRT | q24-48h |
Step 4. Therapeutic drug monitoring
Desired Peak | Desired Trough | |
Gentamicin | 3-5 mg/L | Less than 2 mg/L |
Other Monitoring:
Last reviewed Jan 2023
1. Ali MZ et al. A Meta-Analyis of the Relative Efficacy and Toxicity of Single Daily Dosing Versus Multiple Daily Dosing of Aminoglycosides. Clin Infect Dis. 1997;24(5):796-809.
2. Bailey TC et al. A meta-analysis of extended-interval dosing versus multiple daily dosing of aminoglycosides. Clin Infect Dis. 1997;24(5):786-795.
3. Barza M et al. Single or multiple daily doses of aminoplycosides:a meta-analysis. BMJ. 1996;312(7027):338-45.
4. Stankowicz MS et al. Once-daily aminoglycoside dosing: An update on current literature. Am J Health Syst Pharm. 2015;72(16):1357-64.
5. Pharmacy Services, QEII Health Sciences Centre. Clinical Pharmacokinetic Handbook. 2005.
6. Antimicrobial Stewardship, Sunnybrook Health Sciences Centre. Antimicrobial Guideline: Aminoglycosides. 2019. https://sunnybrook.ca/glossary/item.asp?g=5&c=0&i=1463&page=. Accessed January 2020.
7. SHS + UHN Antimicrobial Stewarship Program. Initiating Aminoglycosides Safely – an Interactive Algorithm. 2016. https://www.antimicrobialstewardship.com/antimicrobials. Accessed January 2020.
8. Lee J et al. Predictive performance of gentamicin dosing nomograms. Drug Des Devel Ther. 2014;8:1097-1106.
9. Ryback MJ et al. Prospective Evaluation of the Efect of an Aminoglycoside Dosing Regimen on Rates of Observed Nephrotoxicity and Ototoxicity.Antimicrob Agents Chemother. 1999;43(7):1549-55.
Last reviewed Jan 2023