University of Pennsylvania Medical Center Guidelines for Antibiotic Use

GUIDELINES FOR ONCE DAILY AMINOGLYCOSIDE DOSING

for cystic fibrosis dosing go to this link

1. Exclusions

Patients treated for suspected or documented endocarditis

Patients with cirrhosis, ascites, or myasthenia gravis - see this link for dosing in cystic fibrosis

Pregnant patients

Dialysis patients

Patients treated for staphylococcal or enterococcal infections when aminoglycoside is used for synergy

Patients in acute renal failure

2. Dosing

A) Calculate Creatinine Clearance (CrCl)

Males: [(140-AGE) x IBW]/[SrCr x 72]

 

Where AGE= age in years

IBW= ideal body weight in kg

IBW in men = 50 kg + 2.3 kg per inch of height over 60 inches

IBW in women= 45.5 kg + 2.3 kg per inch of height over 60 inches

Ideal Body Weight Table

SrCr =Serum creatinine in mg/dl

Females: CrCl(males) x 0.85

B) Dose as follows

Gentamicin/Tobramycin

Dose according to estimated CrCl (see below for dosing weight for obese patients)

CrCl > 50ml/min = 5mg/kg/24hrs

CrCl 30-49ml/min = 5mg/kg/36hrs

CrCl 20-29ml/min = 5mg/kg/48hrs

CrCl <20ml/min,ARF = 2mg/kg X 1 & CONSULT KINETICS

Amikacin

Dose according to estimated CrCl (see below for dosing weight for obese patients)

CrCl > 40ml/min = 15mg/kg/24hrs

CrCl 30-39ml/min = 15mg/kg/36hrs

CrCl 20-29ml/min = 15mg/kg/48hrs

CrCl <20ml/min,ARF = 7.5mg/kg X 1 & CONSULT KINETICS

MAXIMUM DOSE of AMIKACIN = 1500MG

For dosing weight, may use actual body weight (ABW) if not obese.

IF PATIENT IS OBESE (> 20% IBW) take 40% of Excess Weight and add to IBW.

ie. Obese Patient Dosing Weight = 0.4 X (ABW - IBW) + IBW

where ABW= actual body weight

C) ROUND DOSE to the nearest 50MG.

D) Standard Administration time is 2pm

If first dose is given at non-standard administration time:

Patients with high creatinine clearance (> 70ml/min), 2nd dose may be given > 12 hours from first dose, and then 2 pm the next day.

Example:CrCl 70ml/min- 1st dose-10am, 2nd dose-11pm, 3rd dose-2 pm the next day

Patients with low creatinine clearance (< 70ml/min), 2nd dose must be given 24 hours from the first dose.

Example:CrCl 40ml/min- 1st dose-10am, 2nd dose-10am the next day, 3rd dose-2 pm the next day.

3. Labs

At the time of writing for Once Daily Dosing, please order:

Serum Creatinine/BUN every 2days

Random level (8-14 hours before the next dose)

updated 5/4/04 by Lori LaRosa and Paul Edelstein

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