- Treatment of documented or suspected infections caused by susceptible Gram (-) bacilli including Pseudomonas aeruginosa.
- IV Intermittent infusion: over 30 minutes
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EXTENDED INTERVAL DOSING: preferred method. SEE BELOW for therapeutic cooling dose |
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Gestational Age and Post-Natal Age |
Dose |
Therapeutic Drug Levels1 | |
|
Preterm <30 weeks GA |
0- 14 days | 5 mg/kg/dose Q48h |
Target for Extended-Interval trough concentrations:
If renal dysfunction is present, longer dosing intervals and/or lower doses may be required if the aminoglycoside is to be continued.2 A trough value of ≤1mg/L may be considered as the goal in these certain cases; consult clinical pharmacist. Traditional Dosing may be considered (see Notes section) |
| >14 days |
5 mg/kg/dose Q36h |
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|
Preterm 30-34 weeks GA |
0-10 days |
5 mg/kg/dose Q36h |
|
| >10 days |
5 mg/kg/dose Q24h |
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Preterm & Term > 35 weeks
|
0-7 days |
4 mg/kg/dose Q24h |
|
| >7 days |
5 mg/kg/dose Q24h |
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|
Therapeutic Cooling dosing for infants >35 weeks gestation |
3 mg/kg/dose given once. |
Draw PRE level 24 hours later, and wait for result prior to administration of second dose. | |
|
1 TDM may not be necessary if therapy is anticipated to stop at 36-48 hours. A trough level can be obtained prior to the anticipated second dose but may be postponed to pre-third dose if there is no concern for renal dysfunction. Trough levels are obtained 0-60 minutes prior to the next anticipated dose and are a safety measure. 2 This would include neonates with suspected, possible or confirmed hypoxic ischemic events, undergoing therapeutic cooling, fluid imbalance, possible or suspected renal thrombosis, congenital renal anomalies or any other conditions that may be associated with transient or prolonged renal dysfunction. |
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Note that Extended Interval Dosing is preferred at CHEO in normal renal function. For Traditional Dosing, see below.
- Hematologic: anemia, granulocytopenia, thrombocytopenia
- Otic: vestibular/auditory toxicity
- Renal: nephrotoxicity, increase risk with concurrent use of nephrotoxic drugs (eg. furosemide, indomethacin)
- Renal: serum creatinine, urea, urine output
- Therapeutic drug levels: see tables
** When checking level, administer next dose as scheduled. Do not wait for levels to be reported unless otherwise advised
IV intermittent infusion:
CHEO:
- Tobramycin 40 mg/mL (doses < 10 mg)
- Take 1 mL (40 mg) and add to 39 mL D5W
- Final concentration: 1 mg/mL
- Tobramycin 40 mg/mL (doses > 10 mg)
- Take 1 mL (40 mg) and add to 3 mL D5W or 0.9% NaCl
- Final concentration: 10 mg/mL
TOH:
- Tobramycin 40 mg/mL
-
Take 1 mL (40 mg) and add to 39 mL D5W
-
Final concentration: 1 mg/mL
-
- Solutions Compatible: D5W, D10W, 0.9% NaCl, dextrose-saline combinations
- Y-site Compatible: acyclovir, dexmedetomidine, fentanyl, fluconazole, heparin (low concentrations of 0.5 to 1 unit/mL that are used to maintain IV line patency), hydromorphone, midazolam, milrinone, morphine, TPN (amino acids- dextrose)
- Incompatible: heparin (concentration greater than 1 unit/mL), indomethacin, piperacillin/tazobactam, SMOF
- Direct contact of a penicillin antibiotic (eg, ampicillin, piperacillin) with an aminoglycoside (gentamicin, tobramycin) may cause inactivation. Rinse thoroughly between both administration if given via the same line.
- Extended interval dosing is being introduced to help optimize efficacy and minimize aminoglycoside toxicity in this patient population
- A trough level can be obtained prior to the anticipated second dose but may be postponed to pre-third dose if there is no concern for renal dysfunction and if it is anticipated that the duration will be > 48 hours.
- Peak concentrations 6-12 mg/L are generally obtained to see if targets for efficacy are being attained or for pharmacokinetic modeling purposes.
Traditional Dosing (may be used in cases of renal dysfunction, transient or prolonged. Not the preferred method at CHEO)
| Gestational Age & Post Natal Age | Traditional Dose | Therapeutic drug Levels3 | ||
| Preterm (< 36 weeks GA) | 0-14 days | <28 weeks GA | 3 mg/kg/dose Q24h |
Traditional Dosing (Pre and Post levels obtained after 48 hours if renal function remains normal)
Pre (0-30 minutes before dose): 0.5-2 mg/L Post (30 minutes after end of the 30 minute infusion): 5-10 mg/L
If renal dysfunction is present, consult clinical pharmacist2 |
| 29-36 weeks GA | 3.5 mg/kg/dose Q24h | |||
| > 14 days | <28 weeks corrected GA | 3-3.5 mg/kg/dose Q18h | ||
| >29 weeks corrected GA | 3-3.5 mg/kg/dose Q12h | |||
| Term (> 37 weeks GA) | 0-7 days | >37 weeks GA | 3-3.5 mg/kg/dose Q18h | |
| > 7 days | 2.5 mg/kg/dose Q8h4 | Pre and Post levels obtained on Day 3. If renal dysfunction present, consult clinical pharmacist2 | ||
|
2This could include cases of hypoxic-ischemic events, therapeutic cooling, fluid imbalance, renal thrombosis, congential renal abnormalities or any other condition that may cause transient or prolonged renal dysfunction 3TDM may not be necessary if therapy is anticipated to stop at 36-48 hours. Trough (pre) and peak (post) levels are recommended for Traditional Dosing 4Typically, we would start extended interval dosing here (see Extended Interval Chart above), which is the preferred method in normal renal function |
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-Taketomo CK, Hodding JH, Kraus DM. Pediatric and Neonatal Dosage Handbook 22nd Editions. Hudson: Lexi-Comp Inc.; 2015
- Low YS, Tan SL, Wan A. Extended-Interval Gentamicin Dosing in Achieving Therapeutic Concentrations in Malaysian Neonates. J Pediatr Pharmacol Ther. 2015. Mar-Apr, 20 (2): 119-127.
- Bergenwall M, Walker SAN, Elligsen M, Iaboni DC, Findlater C, Seto W, Ng E. Optimizing gentamicin conventional and extended interval dosing in neonates using Monte Carlo simulation - a retrospective study. BMC Pediatr. 2019 Sep 6;19(1):318.
- König K, Lim A, Miller A, Saker S, Guy KJ, Barfield CP. Gentamicin trough levels using a simplified extended-interval dosing regimen in preterm and term newborns. Eur J Pediatr. 2015 May;174(5):669-73. doi: 10.1007/s00431-014-2450-z.
- van Maarseveen EM, Sprij A, Touw DJ. Extended-Interval Dosing of Gentamicin Aiming for a Drug-Free Period in Neonates: A Prospective Cohort Study. Ther Drug Monit. 2016 Jun;38(3):402-6.
-Red Book (Committee on Infectious Diseases, American Academy of Pediatrics); David W. Kimberlin, MD, FAAP, Elizabeth D. Barnett, MD, FAAP, Ruth Lynfield, MD, FAAP, Mark H. Sawyer, MD, FAAP. American Academy of Pediatrics. Publication date: January 2021.
-American Society on Health-System Pharmacists (ASHP). Handbook on Injectable Drugs. 19thEdition. Bethesda: American Society of Health-System Pharmacists; 2017