Dosing and administration of parenteral aminoglycosides
- Richard H Drew, PharmD, MS, FCCP
Richard H Drew, PharmD, MS, FCCP
- Professor, Campbell University College of Pharmacy and Health Sciences
- Associate Professor and Clinical Pharmacist, Infectious Diseases
- Duke University Medical Center
The traditional approach to parenteral aminoglycoside dosing in adults involves the administration of a weight-based dose divided two to three times daily in patients with normal renal function. The dose is reduced and/or dosing interval extended in patients with decreased renal function or as indicated by measured serum drug concentration(s). Extended-interval aminoglycoside therapy (also known as once-daily aminoglycosides, single daily aminoglycoside dosing, consolidated or high-dose aminoglycoside therapy) utilizes a higher weight-based dose administered at an extended interval (every 24 hours for those with normal renal function and longer for those with renal dysfunction). Extended-interval aminoglycoside therapy (utilizing higher single doses) should not be confused with traditional, intermittent dosing with lower individual doses administered at 24-hour intervals because of renal impairment.
This topic discusses the efficacy and safety, patient selection, and implementation of these two dosing strategies. Other (general) information about aminoglycosides is found elsewhere. (See "Aminoglycosides".)
This topic refers to dosing of aminoglycosides for the treatment of typical bacterial infections. Dosing of aminoglycosides in the treatment of mycobacterial infections, tularemia, plague, and brucella are discussed in the topics dedicated to those infections.
Of note, for most of these situations, with the exception of urinary tract infections, aminoglycosides are generally used in combination with other agents that have gram-negative activity, regardless of dosing method. (See "Aminoglycosides", section on 'Clinical use'.)
The rapid attainment of therapeutic concentrations of aminoglycosides has been correlated with improved patient outcomes. Thus, dosing should be optimized to achieve this effect. Additionally, dosing should be tailored to minimize aminoglycoside toxicity. The following general principles apply to all patients, regardless of whether traditional intermittent versus extended-interval daily dosing strategies are used:
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- GENERAL PRINCIPLES
- Dosing weight
- Creatinine clearance estimation
- Monitoring for toxicity
- TRADITIONAL VERSUS EXTENDED-INTERVAL DOSING
- - Nephrotoxicity
- - Ototoxicity
- Convenience and cost
- SELECTION OF DOSING STRATEGY
- GENTAMICIN AND TOBRAMYCIN DOSING IN ADULTS
- Traditional dosing and monitoring
- - Loading dose
- - Initial maintenance dose and dosing interval
- - Drug concentration monitoring
- "Target" concentrations
- - Dosing adjustments
- - Frequency of monitoring
- Extended-interval dosing and monitoring
- - Initial dose and dosing interval
- - Drug concentration monitoring
- Target concentrations
- Nomogram-based monitoring
- Individualized monitoring
- AMIKACIN DOSING IN ADULTS
- STREPTOMYCIN DOSING IN ADULTS
- DOSING FOR SPECIAL CIRCUMSTANCES
- Neonates and children
- Peritoneal dialysis
- Intermittent hemodialysis
- Continuous AV hemofiltration
- Cystic fibrosis
- Burn patients
- Septic patients
- Elderly patients
- Synergy for gram-positive infections
- SUMMARY AND RECOMMENDATIONS