Gentamicin

Dosing: Adult Antimicrobial Dosing, Non-dialysis

Use traditional dosing or consult ID pharmacy for guidance

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
Gram-positive synergy 1 mg/kg IV Q8h Contact pharmacy for assistance
Gram-negative infections, high-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded.  5-7 mg/kg IV q24h Use traditional dosing or contact pharmacy for assistance
Gram-negative infections, traditional dosing: patients who do not qualify for high-dose extended interval dosing 1.6 mg/kg IV q8h 1.5 mg/kg IV q12h 1.5 mg/kg IV q12-24h 2 mg/kg loading dose IV x1, contact pharmacy for maintenance

Dosing: Antimicrobial Dosing in Intermittent & Continuous Hemodialysis

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 mg/kg IV x1, then 1 mg/kg IV post-HD 2 mg/kg IV x1 then 1.5 mg/kg IV q24h

Dialysis Notes

Intermittent HD assumes high-flux hemodialysis. CRRT assumes CVVHD with ultrafiltration rate 2L/h and residual native GFR < 10 mL/min.  For detailed view of dialysis dosing and evidence, see Dosing in Hemodialysis document.

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-positive synergy Paired levels: Check peak drug level 30 minutes after end of infusion (goal 3-4 mg/L) and trough immediately before next dose (goal <1 mg/L)
Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram below.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L).

Nomogram: