Exceptions to use of extended interval dosingGeneral IndicationsCystic FibrosisRenal dysfunction at baseline; consider alternate antibiotic; CNS Infections, Endocarditis.
Synergistic dosing of aminoglycosides with beta-lactams; use conventional dosing.Infants and Children: 4-7mg/kg/DOSE IV q24hAll Ages: 10-12mg/kg/DOSE IV q24h
General IndicationsCystic fibrosisSynergistic dosing of aminoglycosides with beta-lactamsTreatment of Enterococcus speciesInfants and Children: 2-2.5 mg/kg/DOSE IV q8hIV, IM: Usually require higher doses at 2.5 to 3.3 mg/kg/DOSE every 6 to 8 hoursUse low doses of 1 mg/kg/DOSE every 8 hoursMay require synergistic therapy with a full dose of 2.5 mg/kg/DOSE every 8 hours
NoteAny PNAIncluding: weight less than or equal to 1250g, HIE, concurrent nephrotoxic medications, hemodynamic instability requiring vasoconstrictors, and/or renal dysfunction at start of therapy (urine output less than 1mL/kg/hr OR Scr increase of 30% or more)5mg/kg/DOSE IV q48h
PNA less than or equal to 7 daysPNA greater than 7 days5mg/kg/DOSE IV q48h5mg/kg/DOSE IV q24h
PNA less than or equal to 7 daysPNA greater than 7 days5mg/kg/DOSE IV q36h5mg/kg/DOSE IV q24h
Any PNA5mg/kg/DOSE IV q24h
Consult a pharmacist for renal dosing.
Renally cleared, requires dosage adjustment with changes in renal function.
Monitor creatinine at least weekly and more often if levels are elevated or other signs of renal dysfunction arise. Discontinue if any signs of ototoxicity (tinnitus, fullness in ears, dizziness).
Serum Level Monitoring for EXTENDED Interval Dosing, pediatrics: For most patients and indications, no levels are necessary, unless: Patients suspected at high risk for development of nephrotoxicity or renal dysfunction, or duration of treatment more than 5 days. In these cases check trough level prior to any dose to ensure that it is less than 1 mg/L. In cases where there is concern regarding treatment efficacy due to lack of response or severe infection treated with monotherapy, for cystic fibrosis (CF) or febrile neutropenia: Draw TWO levels, one 2 to 3 hours and one 6 to 8 hours after first dose. Refer to Calgary Zone Once Daily Aminoglycoside Calculator (in monograph) to calculate target parameters
Serum Level Monitoring for EXTENDED Interval Dosing, neonates: If plan is to discontinue gentamicin pending 48-hour culture results, no levels are required unless indicated for renal dysfunction. If plan is to continue antibiotics beyond 48 h culture results draw a 22 hour level on all neonates regardless of ordered dosing interval.
If 22 h level is: 1.2 mcg/mL or less- give every 24h.
1.3 to 2.6 mcg/mL- give every 36h
2.7 to 3.5 mcg/mL- give every 48h
3.6 mcg/mL or more- Hold next dose, repeat level in 24 hours. Base interval on time to reach trough level less than 2 mcg/mL. Repeat 22h level if therapy continues beyond 7 days.
Serum Level Monitoring for CONVENTIONAL Dosing: Obtain drug levels with the third or fourth dose. Peak serum levels are drawn 30 minutes after the end of an IV infusion or one hour post-IM injection. Peak levels are: 5 to 10 mcg/mL and 12 to 15 mcg/mL in cystic fibrosis. Trough levels are drawn just prior to the next dose and should be less than 2 mcg/mL.
Serum Level Monitoring for Synergistic Dosing: Levels are typically not required. If done, targets are: Peak 3 to 5 mg/L and trough less than 2 mg/L.
Enhanced nephrotoxic effect with concomitant use of other nephrotoxins.
Enhanced ototoxicity with loop diuretics (e.g. furosemide).
Non-depolarizing muscle relaxants may be potentiated.
Antimicrobial class: Aminoglycoside
Average serum half life:
Neonates: 3-11.5 hours
Infants: 4 ± 1 hour
Children: 2 ± 1 hour
Adolescents:1.5 ± 1 hour
Adolescents: 1.5 ± 1 hour
Adults: 1.5- 3 hours; End stage renal disease: 30-70 hours
Route of Elimination: Almost completely by glomerular filtration of unchanged drug with excretion into urine.