Amikacin

C difficile risk
Low
Oral Bioavailability
N/A

Dosing

Multiple Daily Dose (MDD) Amikacin
15 mg/kg divided q8-12h IV or IM

Once Daily (OD) Dose Amikacin
15-20 mg/kg q24h IV or IM

Mycobacteria
15 mg/kg IV/IM once daily OR 25 mg/kg IV/IM 3 times/week

Class 1, 2, or 3 obesity (BMI ≥30 kg/m2):

IV: Use adjusted body weight for initial weight-based dosing when targeting Cmax/minimum inhibitory concentration (MIC) goals with either loading dose equation (based on target aminoglycoside concentration and estimated Vd) or mg/kg approach and when estimating kidney function with Cockcroft-Gault (CrCl) (Bland 2018; Pai 2014; Traynor 1995). Alternatively, use adjusted body weight to estimate CrCl and aminoglycoside dosing with the Bayesian approach when targeting AUC/MIC goals (Bland 2018; Pai 2014). Note: If aminoglycoside therapy is continued, use Cmax/MIC or AUC/MIC goals to optimize therapy, especially in the critically ill where weight and kidney function may be poor surrogates of Vd and clearance (Hassan 1987; Rughoo 2014).

Rationale for recommendations: Aminoglycosides are hydrophilic medications with a low Vd and clearance that is proportional to GFR. Pharmacokinetic studies have observed adjusted body weight, using a correction factor of 0.4, is the most appropriate weight metric to correct Vd in the setting of obesity. However, there is wide variation in the correction factors reported, which could lead to under- or over-dosing in clinical practice (MacDougall 2011; Pai 2007). Early use of therapeutic drug monitoring is recommended (Pai 2014).

No adjustment required

eGFR 0 - 10eGFR 10 - 20eGFR 20 - 30eGFR 30 - 40eGFR 40 - 50eGFR 50 - 60eGFR 60 - 80 eGFReGFR > 80Only use if no alternatives 3mg/kg q72hOnly use if no alternatives 4mg/kg q48hOnly use if no alternatives 7.5mg/kg q48h4mg/kg q24h7.5mg/kg q24h7.5mg/kg q24h12mg/kg q24h15mg/kg q24h

eGFR 0 - 10eGFR 10 - 20eGFR 20 - 30eGFR 30 - 40eGFR 40 - 50eGFR 50 - 60 eGFR 60 - 80eGFR > 80Only use if no alternatives 7.5mg/kg q48hOnly use if no alternatives 7.5mg/kg q24hUse with caution based on eGFR- 7.5mg/kg q24h7.5mg/kg q24h7.5mg/kg q24h7.5mg/kg q12h7.5mg/kg q12h7.5mg/kg q12h

AVOID aminoglycosides in renal failure patients if possible.

Use 5-7.5 mg/kg after dialysis for each intradialitic period.

Check levels pre-dialysis.

Readminister post dialysis if less than 4mg/L

10 mg/kg load then 7.5 mg/kg q24h

General Information

Therapy of gram negative organisms resistant to gentamicin and tobramycin but susceptible to amikacin (HAP, UTI, other).

As combination therapy for the treatment of some Mycobacteria species (e.g. M. abscessus).

Monitor creatinine at least 3 times/week. Discontinue if any signs of ototoxicity.

For BID dosing: Target Peak 15-30 mg/L, Trough <5 mg/L. Peak levels usually not required but if drawn, record time of dose and time of level draw as accurately as possible.

Consult pharmacist for level interpretation and dose individualization

For once daily dosing: Target Trough <1 mg/L. Peak levels not recommended.

Nephrotoxicity (non-oliguric)

  • Less common with once daily dosing.

  • Avoid concomitant nephrotoxins.

  • Greater toxicity with longer duration and supratherapeutic trough levels.

Vestibulocochlear toxicity

  • Irreversible

  • Audiology testing required for prolonged use

Other

  • Can exacerbate neuromuscular blockade - e.g. contraindicated in patients with myasthenia gravis.

Increased nephrotoxicity with:

  • Amphotericin B

  • Cyclosporine

  • Cisplatin

  • NSAIDS

  • Contrast dye

  • Vancomycin

Increased ototoxicity with:

  • Furosemide

Respiratory paralysis with:

  • Neuromuscular blockade agents

Formal audiology assessment required if planning to use aminoglycoside for >7d or if symptoms develop.

Inform patient of risk of ototoxicity and to report any symptoms.

Antimicrobial class: Aminoglycoside

Pregnancy category: D

Average serum half life: 2.5 hours

Urine penetration: Therapeutic

Lung penetration: Therapeutic

CSF penetration: Poor

Biliary penetration: Moderate

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