Monitoring
Consult with pharmacy
Dosing Weights
Dosing: Adult Antimicrobial Dosing, Non-dialysis
For UCSF pharmacists, access the pharmacy guidance manual click here
Do not use high-dose extended interval dosing strategy (using Hartford nomogram) in the following populations:
- Cr Cl ≤ 20 ml/min - Aminoglycoside t ½ > 4.5 hours - Patients with burns > 20% total burn surface area (TBSA) | - Ascites - Cystic Fibrosis (CF) patients - Pregnancy (outside of surgical prophylaxis) - Spinal cord injury |
High-dose extended dosing strategy:
| Indication | CrCl > = 60 mL/min | 40-59 mL/min | 21-39 mL/min | CrCl < = 20 mL/min | Comments |
|---|---|---|---|---|---|
| Cystitis | 5 mg/kg x 1 | 5 mg/kg x 1 | 5 mg/kg x 1 | Use conventional/traditional dosing | No nomogram or levels needed |
| Other infecions (exclude CF) | 7 mg/kg IV q24h | 7 mg/kg IV q 36h | 7 mg/kg IV q 48h | Use conventional/traditional dosing | Obtain 6-14 hour random gentamicin level after first dose to inform future dosing interval Consider consulting pharmacy to assist with suggested dosing and monitoring Use Harford dosing nomogram Do not use this dosing in CF patients |
Hartford dosing nomogram (gentamicin/tobramycin 7 mg/kg)
Urban Craig (5 mg/kg) dosing nomogram:
Conventional/traditional dosing:
Please consult pharmacy to help with dosing and monitoring plan. Below are suggested peak and trough goals based upon infection:
| Conventional/traditional dosing | ||
| Gentamicin/Tobramycin | ||
| Infection | Extrapolated Peak Goal | Extrapolated Trough Goal |
| Abdominal Infections (including peritonitis) | 6-8 | < 1 (0.5) |
| Bacteremia | 6-8 | < 1 (0.5) |
| Empiric therapy for Cystic Fibrosis (if cannot do high-dose extended interval dosing) | Extended interval preferred but if impaired renal function consider 8-12 for peak and < 1 (0.5) for trough | |
Endocarditis Gram positive (‘synergy in divided doses’) * Gram negative |
3-4 8-10 |
< 1 (0.5) < 1 (0.5) |
| Neutropenic Fever | 6-10 | < 1 (0.5) |
| Pneumonia | 8-10 | < 1 (0.5) |
Skin and soft tissue infections | 6-8 | < 1 (0.5) |
| Urinary tract infections (including pyelonephritis) | 4-6 | < 1 (0.5)
|
| Indication | CrCl > = 60 mL/min | 40-59 mL/min | 21-39 mL/min | CrCl < = 20 mL/min | Comments |
|---|---|---|---|---|---|
| Gram-positive synergy infective endocarditis (IE) involving Staphylococcus spp. and Enterococcus spp. | 1 mg/kg IV q 8h consult pharmacy to assist with pharmacokinetics calculations | 1 mg/kg IV q 12h consult pharmacy to assist with pharmacokinetics calculations | Use conventional/traditional dosing | Use conventional/traditional dosing | |
| Gram-positive syngergy in Streptococcus spp. infective endocarditis (IE) | 3 mg/kg IV q 24h | Use conventional/traditional dosing | Do not use this dosing strategy in Staphylococcus and Enterococcus spp. IE No optimal drug concentrations identified with this dosing strategy – contact ID pharmacy for guidance | ||
Cystic fibrosis (CF) patients:
Gentamicin is not a preferred agent to be used in Pseudomonas aeruginosa infections - avoid use.
Dosing: Antimicrobial Dosing in Intermittent & Continuous Hemodialysis
| Indication | Intermittent Hemodialysis | Continuous Hemodialysis |
|---|---|---|
| All indications | Use conventional/traditional dosing Consult pharmacy to assist | Consult pharmacy to assist with dosing strategy |
Dialysis Notes
Advise caution in individuals with myasthenia gravis. Aminoglycosides should never be used as monotherapy except in the setting for a urinary tract infection (UTI).