C difficile risk
Oral Bioavailability


Once Daily Dosing 5-7mg/kg IV q24h

Multiple Daily Dosing 1.5-2mg/kg IV q8h

N.B. Use Dosing Weight (aka. Adjusted Body Weight) for obese patients

eGFR 0 - 10eGFR 10 - 20eGFR 20 - 30eGFR 30 - 40eGFR 40 - 60eGFR 60 - 80eGFR > 80 Only use if no alternatives - 2mg/kg IV q72hOnly use if no alternatives - 3mg/kg IV q48hOnly use if no alternatives - 4mg/kg IV q48h2.5mg/kg IV q24h3.5mg/kg IV q24h4mg/kg IV q24h5-7mg/kg IV q24h

eGFR 0 - 10eGFR 10 - 30eGFR 30 - 50eGFR > 50Only use if no alternatives - 1.7mg/kg q48hUse with caution based on eGFR - 1.7mg/kg IV q24h1.7mg/kg IV q12-24h1.7mg/kg IV q8h

3mg/kg IV load

Mild infection/synergy 1mg/kg IV q48-72h. Redose when pre-HD <1mcg/mL

Severe infection 2mg/kg IV q48-72h. Redose when pre-HD <3mcg/mL

Usual dosing 3mg/kg load then 2mg/kg IV q24h

Synergistic dosing 1mg/kg IV q24h

General Information

Empiric (in combination) or targeted therapy for suspected or confirmed gram negative infections.

Empiric therapy for pyelonephritis.

Used synergistically in enterococcal endocarditis.

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

Once daily dosing: Target trough <1mcg/mL

Multiple daily dosing: Peak monitoring poorly supported by literature, but target peak 4-10mcg/mL; trough 1-2mcg/mL only if using >4 days

NB: Trough level is 0-60min before a dose (usually pre-4th), and peak is 30-60min after dose infused (usually post-3rd).

In critically ill patients, check peak level after the 1st dose as volume of distribution and renal function may change rapidly.

Nephrotoxicity (non-oliguric)

  • Avoid concomitant nephrotoxins

  • Less common with once daily dosing

  • Greater toxicity with longer duration and supratherapeutic trough levels

Vestibulocochlear toxicity

  • Irreversible

  • Require audiology testing if prolonged use

Can exacerbate neuromuscular blockade

  • Contraindicated in patients with myasthenia gravis

Increased nephrotoxicity

  • Amphotericin

  • Vancomycin

  • Cyclosporin

  • NSAIDs

  • Contrast

Increased ototoxicity

  • Loop diuretics (e.g. furosemide)

Non-depolarizing muscle relaxants may be potentiated

Formal audiology assessment 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 hours

Urine penetration: Therapeutic

Lung penetration: Therapeutic

CSF penetration: Poor

Biliary penetration: Moderate

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