(BQ) Part 2 book Antibiotic guidelines 2015-2016 presents the following contents: Informational guidelines (Approach to the patient with a history of penicillin allergy), informational guidelines (Hospital epidemiology & infection control, infection control precautions, disease specific infection control recommendations), appendix.
Penicillin reactions Incidence Uấấấnọọấvấô>èièấĩấiôèấèiịấ>iấ>i}Vằấèấ* ấ>Vèế>ịấ>iấ negative skin tests and are not at increased risk of an allergic reaction Uấấ*iVấi>VèấvấiấèịôiấVVếấấọầấèấÊọấvấ>ấô>èièấ who get the drug Uấấ 1/\ấ/iấV`iViấvấ>>ôị>VèVấi>Vèấấọọọ{ấèấọọÊx Uấấ,>èiấvấVi>Vèấ>i}iấèấViô>ôấ>iấếĩấLếèấ thought to be low Uấấ,>èiấvấ* ấ>`ấV>L>ôiiấấèièấVấi>Vèèịấ>iấ{ầ]ấ although clinical rates of hypersensitivity reactions in patients with iôèi`ấ* ấ>i}ịấĩấiViiấV>L>ôiiấ>iấqÊÊ Uấấ ấi>VèấèấL>Vè>ấưõèi>đấ`ấ "/ấ>ôôi>ấèấVVế Penicillin skin testing Uấấ7iấ`iấViVèị]ấấ}ịấôi`Vèiấvấiế]ấ>>ôị>VèVấi>Vè Uấấ*>èièấĩèấ>ấi}>èiấấèièấ>iấNOT at risk for anaphylactic reactions Uấấ,>iị]ấấèièấi}>èiấô>èièấ>ịấ}ièấ`ấiấ>`ấèV}ấ following penicillin administration but these RESOLVE with continued treatment Uấấ-ấèièấV>èấôi`Vèấ`i>è}Vấấấi>Vèấấ`ế}ấvii Uấấ-ấèiè}ấấĩấ>>>Liấ>èấấ*i>iấVếèấi}ịấ>`ấ Immunology Penicillin reactionsTypes UấImmediateấưèịôiấÊđấqấ>ôị>í]ấịôèi]ấ>ị}i>ấi`i>]ấ wheezing, angioedema, urticaria Uấấèấ>ĩ>ịấVVếấwithin hour of administration Hypotension always occurs soon after administration Uấấ >ấLiấôi`Vèi`ấLịấấèiè UấAcceleratedấqấ >ị}i>ấi`i>]ấĩiiõ}]ấ>}i`i>]ấếèV>>ấ (NOT hypotension) Uấấ"VVếấĩèấÊầểấếấvấ>`è>è Uấấ >ấLiấôi`Vèi`ấLịấấèiè UấLateấqấ,>ấư>Vếô>ôế>ấấLvấấVè>Vèấ`i>èèđ]ấ destruction of RBC, WBC, platelets, serum sickness Uấấèấ>ĩ>ịấVVếấ>vèiấầểấếấvấ>`è>è Uấấ,>iấièiấ}ấ>ĩ>ịấ`iôèiấVèếi`ấèi>èiè Uấấ >Vếô>ôế>ấ>`ấLvấ>iấ "ấ "/ấô}iấèấ Stevens-Johnson syndrome Uấấ >èiấi>Vèấ>iấ "/ấôi`Vèi`ấLịấấèiè UấStevens-Johnson Syndromeấqấiív>èiấ`i>èèấĩèấếVếấ membrane involvement 137 7.1 Approach to the patient with a history of penicillin allergy Approach to the patient with a history of penicillin allergy 7.1 Approach to the patient with a history of penicillin allergy Uấấèấ>ĩ>ịấVVếấ>vèiấầểấếấvấ>`è>è Uấấ "/ấôi`Vèi`ấLịấ>ấèịấvấ>ấ",ấLịấấèiè Approach to the patient with reported penicillin allergy Uấấ iv]ấvVếi`ấèịấV>ấLiấ6 ,9ấiôvế UÊÊ+ÕiÃÌÃÊÌÊ>Ã\ How long after beginning penicillin did the reaction occur? Was there any wheezing, throat or mouth swelling, urticaria? If a rash occurred, what was the nature of the rash? Where was it and what did it look like? Was the patient on other medications at the time of the reaction? Since then, has the patient ever received another penicillin or Vi« >ëÀÊ>ÃÊ>LÕÌÊÌÀ>`iÊ>iÃÊi\ÊÕ}iÌ]Ê iyiÝ]Ê Trimox, Ceftin, Vantin)? If the patient received a beta-lactam, what happened? Interpreting the history of the patient reporting penicillin allergy UÊÊANY patient who has a history consistent with an immediate reaction (laryngeal edema, wheezing, angioedema, urticaria) SHOULD NOT receive beta-lactams without undergoing skin testing first EVEN IF they have received beta-lactams with no problems after the serious reaction Uấấ*>èièấĩấiôèấ>>ôị>VèVấi>Vèấ>`ấ>iấiVii`ấ other penicillins without problems DO NOT have penicillin allergy and are not at increased risk for an allergic reaction compared to the general population Uấấ*>èièấĩấiôèấ>>ôị>VèVấi>Vèấ>`ấ>iấiVii`ấ cephalosporins can get cephalosporins but not necessarily PCNs Uấấ*>èièấĩấiôèấ>ấèịấvấ>ấếèV>>ấ>ấè>èấấ "/ấ consistent with Stevens-Johnson syndrome (target lesions with mucous membrane inflammation) and developed after ≥ 72 hours of penicillin are not at increased risk for an adverse reaction They should, however, be watched closely for development of rashes Ê*>ÌiÌÃÊÜ ÊÀi«ÀÌÊÀi>VÌÃÊVÃÃÌiÌÊÜÌ ÊÃiÀÕÊÃViÃÃÊ (rare) can receive either penicillins or cephalosporins with careful monitoring for recurrence Uấấ*>èièấĩấiôèấấịôèấư`>i>]ấ>ếi>đấôL>Lịấ`ấ not have penicillin allergy and not appear to be at increased risk for an adverse reaction They should be closely observed for recurrent symptoms and be given supportive therapy if they occur ,iviiVi\ấ ấểọọÊặểnx\ể{n 1iấvấV>L>ôiiấấô>èièấĩèấ* ấ>i}ị\ấấèVLấ ièiấểọọ{ặx{\ấ ÊÊxxqầấ ấèiấ i`ấểọọầặÊ{ẩ\ểẩẩq 138 Uấấ ếèấèiấ ấĩiLèiấấấôViấiấư*"đấưĩĩĩ hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies, and surveillance information Hand hygiene ÊvÊ >`ÃÊ>ÀiÊÌÊÛÃLÞÊÃi`]ÊÌ iÊ>V L>Ãi`Ê >`ÊÃ>ÌâiÀÃÊ>ÀiÊ recommended for cleaning If hands are visibly soiled, wash hands with soap and water for at least 15 seconds Uấấ>`ấị}iiấấiàếi`ấếôấièi}ấ>ấô>èièấ]ấếôấiíè}]ấ between patients in a semi-private room, and other times per hospital policy Ê1ÃiÊÃ>«Ê>`ÊÜ>ÌiÀÊÕ«Êexiting the room of a patient with C difcile infection Uấấ ấ>èwV>ấw}i>ấ>iấôièèi`ấvấ>ịấè>vvấiLiấĩấ>ấ patient contact or handles sterile supplies Bloodborne pathogen exposures (needlestick or other exposure) The prompt treatment of injuries and exposures is vital to prevent the transmission of disease Whatever the exposure, IMMEDIATE cleaning of the exposure site is the rst priority Uấấ-ấĩế`ấế`ấLiấVi>i`ấĩèấ>ôấ>`ấĩ>èi Uấấ ếVếấiL>iấế`ấLiấyếi`ấèế}ịấĩèấĩ>èi Uấấ ịiấế`ấLiấ}>èi`ấĩèấ>ấèiấvấ>ấ>i vèiấVi>}ấèiấiíôếiấèi]ấV>ấx-/8ấưxần{đấ>`ấvĩấ instructions to contact the ID physician Workplace injuries should be iôèi`ấi`>èiịấấèiấ ôịiiấ,iôèấvấV`ièấằấ>`ấ to the Occupational Injury Clinicấư >VấÊẻ]ấ `>ịq`>ị]ấầ\ẻọấ a.m to p.m., 5-6433), and to your supervisor Standard Precautions Uấấ,ếèiấ>`ấị}iiấ Uấấ èièấ>`ấViVèấ}iấếiấấ Uấấ >}ấVè>>èi`ấiấ>èấôèấvấếi Uấấ,i}ế>ấVi>}ấvấiiè>ấ surfaces Uấôôô>èiấếiấvấ}ĩấèấôiièấấ Uấ,ếèiấVi>}ấấ`ô>ấv contamination of uniform/clothing patient-care equipment Uấôôô>èiấếiấvấ>]ấiịiấấ UÊ-ÌÀVÌÊ>` iÀiViÊÌ protection and face shields (i.e., when occupational safety requirements suctioning, or when splash likely) 139 8.1 Hospital Epidemiology & Infection Control A Hospital Epidemiology and Infection Control (HEIC) 8.1 Hospital Epidemiology & Infection Control A Communicable diseases—exposures and reporting Êà Õ`ÊLiÊÌwi`\ ÊvÊ«>ÌiÌÃÊÀÊ 7ÃÊ>ÀiÊiÝ«Ãi`ÊÌÊ>ÊVÕV>LiÊ`Ãi>ÃiÊ°i°Ê meningococcal disease, varicella, TB etc.) ÊLÕÌÊ 7ấĩèấ>Vếèiấiô>èèấ]ấ ấấ ]ấ->i>]ấ-}i>]ấ Campylobacter, or pneumonia requiring hospital admission UấấLếèấ>ịấếếế>ấVVếiViấvấ`i>iấấVếèi]ấô>èVế>ịấ diseases that have the potential to expose many susceptible individuals Ê-ÕëVÊÀÊ`>}ÃiÃÊvÊÌ iÊvÜ}Ê`Ãi>ÃiÃÊ`Ãi>ÃiÃÊÜÌ Ê require immediate notification by phone or pager) If disease is in a HCW, notify HEIC and Occupational Health (98 N Broadway, -ếèiấ{ểÊ]ấ `>ịq`>ị]ấầ\ẻọấ>ấèấ{\ọọấô]ấxẩểÊÊđấ immediately Anthrax Avian Inuenza Botulism Brucellosis Creutzfeldt-Jakob disease (CJD) Diphtheria Glanders Highly resistant organisms (i.e VISA, VRSA) Legionellosis Measles (rubeola) Meningococcal disease Monkeypox Mumps Pertussis Plague Poliomyelitis Q Fever Rabies Ricin toxin Rubella (German measles) Salmonellosis SARS Scabies Shigellosis Smallpox (orthopox viruses) Streptococcal Group A or B invasive disease Tuberculosis Tularemia Varicella (chickenpox or disseminated zoster) Viral hemorrhagic fever Yellow Fever Physicians are required to report communicable disease to the >èiấ èịấi>èấ iô>èièấư{Êọẻẩ{{ẻẩ]ấv>í\ấ{Êọẩểxọẩnnđấ For a complete list of communicable diseases, see the HEIC Web site, Ì iÊ ấ7iLấèi]ấèèô\ẫẫ`i>`>ị>`}ẫ-èi*>}iẫĩ>è to-report.aspx or the BCHD Web site, www.baltimorehealth.org/acd html 140 141 To enter room MRSA, C.diff, zoster§ Door closed Mask/Eye Protection Gown and Gloves Examples Droplet Precautions (orange) Required unless cohorted* No If within feet of patient To enter room Influenza, bacterial meningitis Yes PAPR or N95† to enter room No TB, disseminated zosterĐ Airborne Precautions (blue) ả Required 8.2 Infection control precautions * Required for pertussis and diphtheria † Fit-testing is required to use an N95 mask for airborne precautions ‡ HCWs who are Varicella-immune not have to wear a PAPR or N95 if patient is in isolation for zoster or chickenpox § Disseminated zoster, zoster in an immunocompromised host, and chickenpox require both Contact and Airborne Precautions (sign color) Private room Contact Precautions (pink) Required unless cohorted No No JHH Precautions Categories These precaution categories must be used in addition to Standard Precautions The following table includes general requirements for precaution categories The complete table and the type of isolation required for each organism can be found on the HEIC website If recommendations on this table cannot be followed, please contact HEIC 8.3 Disease-specific infection control recommendations Disease-specific infection control recommendations Carbapenem-resistant Enterobacteriaceae (CRE) Routine active surveillance cultures for CRE are performed in patients who have been hospitalized in a country other than the U.S in the past months Patients are placed on Contact Precautions pending cullture results The results are to be used for isolation purposes, not to guide therapy or clinical care The overwhelming majority of positive surveillance cultures represents colonization, not infection, and should not prompt any antimicrobial therapy Creutzfeldt-Jakob disease (CJD) CJD, variant CJD and other diseases caused by prions are resistant to a number of standard sterilization and disinfection procedures Iatrogenic transmission of CJD has been associated with percutaneous exposure to medical instruments contaminated with prion/central nervous system (CNS) tissue residues, transplantation of CNS and corneal tissues and recipients of human growth hormone and gonadotropin Transmission of CJD has not been associated with environmental contamination or from person-to-person via skin contact The following additional precautions must be made when processing equipment that could be contaminated ĩèấôấi>èi`ấ>èi>\ Uấấ èvịấ ấ>`ấèiấếèấ>>}iẫV>}iấếiấi`>èiịấvấ>ịấ suspected or confirmed CJD case and refer to the CJD policy on the HEIC Web site Uấấ1iấ`ô>LiấiàếôièấĩiiiấôLiấvấ`ô>Liấ equipment is used, Central Sterile Department shall be notified prior to the start of the procedure Uấấ >Liấ>ấ>L>èịấ>`ấô>è}ịấiàếèấ>ấếôiVèi`ấ ấ>`ấ notify the lab before sending specimens Uấấ/iấvĩ}ấ>iấV`ii`ấ}ịấviVèiấ>`ấế`ấLiấ>`i`ấ ĩèấiíèiiấV>ếè\ấL>]ấô>ấV`]ấôèVấèếiấ>`ấôèếè>ịấ gland Uấấ/iấvĩ}ấ>iấV`ii`ấèấLiấvấĩiấviVèèị\ấ -]ấ`iị]ấ liver, lung, lymph nodes, spleen, placenta, tonsillar tissue and olfactory tissue Methicillin-resistant Staphylococcus aureus (MRSA) Routine active surveillance cultures for MRSA are performed on select units to identify patients with MRSA When a culture is positive for MRSA the patient is placed on Contact Precautions The results are to be used for isolation purposes, not to guide therapy or clinical care The overwhelming majority of positive surveillance cultures 142 8.3 Disease-specific infection control recommendations ÊvÊ«À}i`ÊÃÌÃÊVÌ>VÌÊVVÕÀÃÊÜÌ Ê>ÊÃV>LiÃÊ«>ÌiÌ]Ê prophylactic treatment is required Healthcare workers should contact HEIC if an exposure is suspected Vancomycin-resistant enterocci (VRE) Routine active surveillance cultures for VRE are performed on select units to identify patients with VRE Surveillance culture results are found ấèiấiiVèVấô>èièấiV`ấĩèấèiấèièấ>iấ >Vèi}ị-è 6, ấ-èấ-ếấ ếèằấ7iấ>ấVếèếiấ}ĩấ6, ]ấèiấô>èièấấy>}}i`ấ for Contact Precautions The results are to be used for isolation purposes, not to guide therapy or clinical care The overwhelming majority of positive surveillance cultures represents colonization, not infection, and should not prompt any antimicrobial therapy Surveillance cultures should be obtained upon admission and weekly ÊÌ iÊvÜ}ÊÕÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê7®]Ê /Ê>`Ê Leukemia units, NCCU, PICU The patient must be off antibiotics for ≥ 48 hours and cultures from original site of infection AND stool or perirectal cultures taken ≥ week apart must be negative Once this is accomplished, call HEIC to review culture data and initiate deflagging Varicella-Zoster Immunocompetent patients with disseminated zoster and all immunosuppressed patients with zoster need Contact AND Airborne Precautionsấ/iấvĩ}ấ`iwèấ>ôôịấèấô>èièấĩèấõèi\ UấấImmunosuppressed:ấLiấ>ĩấè>ô>èấĩèấèiấô>èấịi>ặấ >Vếèiấiếi>ặấ`ấ}>ấè>ô>èấiVôièặấô>èièấiVi}ấ cytotoxic or immunosuppressive treatments, including steroid treatment for ẻọấ`>ịấĩèấèiấvĩ}ấ`i\ấ`ií>iè>iấ mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily, ôi`iấểọấ}ấ`>ị]ấièịôi`iấÊẩấ}ấ`>ịặấ6ấô>èièấ with CD4 < 200 UấấDisseminated: lesions outside of contiguous dermatomes 144 Aminoglycoside dosing weight: Calculate Ideal Body Weight (IBW) IBW female (kg)ÊrÊ(2.3 x inches over 5’)ʳÊ45.5 IBW male (kg) r (2.3 x inches over 5’)ʳÊ50 For patients < 20% over IBW, use Actual Body Weight (ABW) For patients ≥ 20% over IBW, use Dosing Body Weight (DBW) 7®ÊrÊQ 7ʳÊä°{Ê 7ÊqÊ 7®RÊ Estimation of creatinine clearance (CrCl) by Cockcroft-Gault equation: (If a patient’s renal function is declining, this equation may overestimate CrCl) Ê À Êr £{äÊqÊ>}i®ÊÜi} ÌÊÊ}I® x 0.85 (if female) 72 (serum creatinine) * Use Actual Body Weight (ABW) unless patient ≥ÊÓä¯ÊÛiÀÊ 7]ÊÕÃiÊ 7Ê>ÃÊ`iÃVÀLi`Ê above Extended-interval dosing, also sometimes referred to as “oncedaily” administration, utilizes higher dose and less frequent aminoglycoside administration, whereas patient-specific dosing, previous referred to as “traditional dosing”, typically utilizes smaller doses with more frequent administration See table below for dosing recommendation based on indication and patient’s renal function For mycobacterial infections, urinary tract infections, SICU/WICU protocol and gram-positive synergy (e.g endocarditis), please see separate sections below For cystic fibrosis patients, see the Cystic Fibrosis section (p.92) 145 A Aminoglycoside dosing and monitoring A Aminoglycoside dosing and monitoring Aminoglycosides enhance the efficacy of some antibiotics Except for urinary tract infections, aminoglycosides should seldom be used alone to treat infections A Aminoglycoside dosing and monitoring A Aminoglycoside dosing for Gram-negative infections IndicationsÊ DosingÊ Ê Patient-specific dosing ,i>Êv>ÕÀi]ÊÊ É 66 ]Êi`V>À`ÌÃ]ÊÊ Gram-negative infections (in combination with beta-lactams), CNS infections, septic shock, burn patients, patients with altered volume status (e.g ascites, anasarca, trauma) ấ iấư}đấrấ`ii`ấôi>ấíấQ7i}èấư}đấíấ6`ấấ ư ẫ}đRấ ấ Ê Ê Ê iÃÀi`Ê«i>\ choose from below Ê7i} Ì\ ABW or DBW ÊVolume of distribution (Vd) typically ranges LiÌÜiiÊä°ĨxÊqÊä°xÊ É}ÊÊÃÌÊ«>ÌiÌÃ°Ê Higher Vd should be used in critically ill and volume overloaded patients Ê Ê Ê Ê Ã}ÊÌiÀÛ>ÊL>Ãi`ÊÊ À \ À ÊÈä\Ê+nI À ấẻọẩọ\ấ+Êể ấẻọẫ 66 ẫ \ấ`iấLịấii Extended-interval dosing Uấấ >ấi>ấvếVèấư À Ê >60 mL/min) and all other indications not listed under patient specic dosing iè>Vẫ/L>ịV\ xầấ}ẫ}ấ6ấ+ể{ >V\ 15-20 mg/kg IV Q24H *If targeting high peaks, use maintenance dose frequency of Q12-24H Desired Peaks and Troughs Peak Pneumonia Septic shock Endocarditis Osteomyelitis MDR organismsÊ Trough Gentamicin/ Tobramycin 10 mcg/mL Amikacin 8-10 mcg/mL 20-30 mcg/mL 25-35 mcg/mL This dosing strategy is designed ÌÊÌ>À}iÌÊÌ iÊvÜ}\ Peak iÌ>VÉ/LÀ>ÞV\Ê£ÈĨä mcg/mL >V\Ê{äÈäÊV}É Trough iÌ>VÉ/LÀ>ÞV\Ê £ÊV}É >V\Ê{ÊV}É 10-20 mcg/mL 45-50 mcg/mL L>Ãi`ÊÊ Ê L>Ãi`ÊÊ Ê Gentamicin/ Amikacin Tobramycin All IndicationsÊ £ÓÊV}É Ê £äÊV}É Therapeutic Trough: draw 30 minutes prior to the 3rd dose If the patient meets ANY of the Drug criteria below, a trough level Monitoring Peak: obtain hour after end of infusion, after is recommended prior to the the 3rd dose Ĩ`Ê`Ãi\ Ê VÌ>ÌÊi« ÀÌÝVÊ Frequency of monitoring medications Ê Ê"ViÊ>ÊÜiiÊ>vÌiÀÊ`iÃÀi`Ê«i>ÉÌÀÕ} ÊÃÊ Ê ÌÀ>ÃÌÊiÝ«ÃÕÀiÊ established in patients with normal renal }iÊ≥ 60 years function Ê*>ÌiÌÊÃÊÊÌ iÊ Ê Ê ÀiÊÌ >ÊViÊÜiiÞ\Ê Uấấ"èiấấvấiôèíVèịấ After changes in dosing regimen ưi}ấ`>Lièi]ấ`iịấ/8đ Patient is on dialysis If trough higher than desired Patient in acute renal failure, SCr increased troughs, use patient specic Lịấọxấ}ẫ` ấấẻọvấL>iiấ dosing to adjust dose Major changes in the patient’s volume status 146 Amikacin is the preferred agent to treat all mycobacterial infections, except Mycobacterium chelonae For M chelonae infections, Tobramycin is the recommended aminoglycoside Streptomycin is another aminoglycoside sometimes used to treat mycobacterial infections such as M tuberculosis Please contact the Antimicrobial Stewardship Program pharmacist for Tobramycin/Streptomycin dosing recommendation for this indication Amikacin: À>ÊÀi>ÊvÕVÌ\ "ViÊ`>Þ\Ê£xÊ}É}Ê6Ê+Ĩ{ÊÀÊ£äÊ}É}Ê6Ê+Ĩ{ÊvÊxäÊÞi>ÀÃÊvÊ age) / ÀViÊÜiiÞ\ÊĨxÊ}É}Ê6ÊÌ ÀiiÊÌiÃÊ>ÊÜiiÊ>ÞÊLiÊÀiÊ`vwVÕÌÊ to tolerate) LÀ>ÊÀi>ÊvÕVÌ\ Discuss with pharmacy clinical specialist Therapeutic drug monitoring: Peak and trough not generally iVi>ị]ấiíViôèấấèiấĩèấi>ấếvwViVịấư,ấẩọấ ẫđấ >`ấvấ- ấVi>iấLịấọxấ}ẫ` ấấẻọấvấL>iiấĩiấô>èièấ on aminoglycoside therapy Check a trough concentration to monitor for toxicity Peaks in the low 20 mcg/mL range are acceptable, and trough VViè>èấ>iấôivi>Lịấ{ấVẫ ấấế`ièiVè>Li Aminoglycoside dosing in urinary tract infections CrCl (mL/min) ≥60 40-59 20-39 ÓäÊ Gentamicin/Tobramycin mg/kg IV Q24H or mg/kg IV Q8H mg/kg Q12H mg/kg Q24H £Ê}É}Ê" IÊ Amikacin 10 mg/kg IV Q24H or mg/kg IV Q8H mg/kg IV Q12H mg/kg IV Q24H ỴÊ}É}Ê6Ê" I *Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level £ÊV}É ÊÀÊ>VÊ{ÊV}É }ịV`iấ>iấ}ịấVViè>èi`ấấếiặấèiivi]ấèi>ôiếèVấ drug monitoring is not necessary in patients with normal renal function Suggested doses in the above table will likely provide adequate urine concentrations for highly susceptible organisms Trough should be checked to monitor for toxicity in patients with renal insufciency ư,ấẩọấ ẫđấ>`ấvấ- ấVi>iấLịấọxấ}ẫ` ấấẻọấvấ baseline while patient on aminoglycoside therapy UấấGentamicin/Tobramycin:ấ`ii`ấèế}ấÊấV}ẫ ấấế`ièiVè>Liấ UÊÊAmikacin:Ê`iÃÀi`ÊÌÀÕ} Ê{ÊV}É ÊÀÊÕ`iÌiVÌ>Li° 147 A Aminoglycoside dosing and monitoring A Aminoglycoside dosing in mycobacterial infections A Aminoglycoside dosing and monitoring A Aminoglycoside dosing in the SICU/WICU Gentamicin/Tobramycin Loading dose mg/kg using actual body weight, followed by a patient-specific maintenance dose Amikacin Loading dose 16 mg/kg using actual body weight, followed by a patient-specific maintenance dose Therapeutic Drug Monitoring vÌiÀÊ>`}Ê`Ãi\Ê£Ê ÕÀÊ«i>Ê>`ÊnÊ ÕÀÊiÛiÊ>vÌiÀÊÌ iÊi`ÊvÊÌ iÊ infusion to facilitate calculating patient specific kinetic parameters Aminoglycoside dosing for Gram-positive synergy Dosing for patients with normal renal function: UấGentamicin\ấẻấ}ẫ}ấ6ấViấ`>ịấấiVi`i`ấvấèi>èièấ of endocarditis with Viridans streptococci or S bovis in patients with normal renal function (CrCl Ն 60 ml/min) UÊÊGentamicin: mg/kg IV Q8H is recommended for treatment Enterococcal and other Gram-positive endocarditis infections in patients with normal renal function (CrCl Ն 60 ml/min) Patients >65 years old should be started on Q12H if normal renal function Dosing adjustment for renal insufficiency CrCl (mL/min) {äqxÊÊ ĨäqỴÊÊ ĨäÊ Dosing £Ê}É}Ê+£Ĩ £Ê}É}Ê+Ĩ{ £Ê}É}Ê" I IÊÊÛiÊiÊ`Ãi]ÊV iVÊiÛiÊÊÓ{Ê ÕÀÃ]ÊÀi`ÃiÊÜ iÊiÛiÊ£Ê}É NOTE: See infective endocarditis guidelines (p 65) for duration THERAPEUTIC DRUG MONITORING Ê*i>Ê>`ÊÌÀÕ} Ê>ÀiÊÀiVi`i`Ê>ÀÕ`ÊÌ iÊÌ À`Ê`ÃiÊÌÊ>ÃÃÕÀiÊ appropriate dosing Ê iÃÀi`ÊÃiÀÕÊVViÌÀ>ÌÃÊvÊGentamicin Peak levels:ÊỴqxÊV}É Trough levels:ÊÊ£ÊV}É 148 ... mg/kg IV Q24H or mg/kg IV Q8H mg/kg Q12H mg/kg Q24H £Ê}É}Ê" IÊ Amikacin 10 mg/kg IV Q24H or mg/kg IV Q8H mg/kg IV Q12H mg/kg IV Q24H ỴÊ}É}Ê6Ê" I *Give one dose, check level in 24 hours,... patient specic dosing iè>Vẫ/L>ịV xầấ}ẫ}ấ6ấ+ể{ >V 15 -20 mg/kg IV Q24H *If targeting high peaks, use maintenance dose frequency of Q 12- 24H Desired Peaks and Troughs Peak Pneumonia Septic shock... (kg)ÊrÊ (2. 3 x inches over 5’)ʳÊ45.5 IBW male (kg) r (2. 3 x inches over 5’)ʳÊ50 For patients < 20 % over IBW, use Actual Body Weight (ABW) For patients ≥ 20 % over IBW, use Dosing Body Weight (DBW) 7®ÊrÊQ 7ʳÊä°{Ê 7ÊqÊ 7®RÊ