GENERAL:

1. Guidelines applicable to young "healthy" adult population only.

2. Creatinine clearance (CrCl) determines the regimen to use. (Equations are at end of guidelines)

3. Dosage based on adjusted body weight (ABW). (Equations are at end of guidelines)

4. After calculation round dose to nearest 10mg.

5. Contact the pharmacy for any dosing adjustment assistance.

ONCE DAILY DOSING GUIDELINES:

1. Use only if CrCl is greater than 60 ml/minute

2. DO NOT USE in the following patients: febrile neutropenia, cystic fibrosis, burns, spinal cord injuries, meningitis, � � endocarditis, or infections with enterococcus.

3. Standard infusion time is one hour.

4. Monitor concentration 18 hours after first dose:

� � � � - Concentration must be less than 1mcg/ml to continue once daily dosing

� � � � - If concentration > 1 mcg/ml, initiate standard dosing

5. Dose: Adult 5mg/kg/day (CrCl < 60ml/min use standard dosing)

� � � � � � � Elderly 4mg/kg/day

STANDARD DOSING GUIDELINES:

1. Use in patients with CrCl less than 60ml/minute.

2. Standard infusion time is one hour.

3. Concentration times: Peak = 0.5 hr after 1 hr infusion; trough within 30 min prior to next dose.

4. Loading Dose: Based on type of infection (Note: loading dose may not be necessary in all cases)
Infection Type � � �� �� � � � � � � � �� � � � � � � � � � � � � � � � � ��Loading Dose
UTI, endocarditis � � � � � � � � �� �� �� � � � � �� �� �� � � � � � � � � �1.5 mg/kg
Sepsis, gram negative infection � � � � � � � � � � � � � � � � � � � � 2.5 - 3.0 mg/kg

5. Maintenance Dose: Based on CrCl

� � �- Usual dose: 3 - 5 mg/kg/day

� � �- Dosing interval should be at least q 12 hours for most patients > 50 years old or at risk of nephrotoxicity

CrCl (ml/min)	Dose (% of loading dose)	Dose interval (hrs)
> 60	90	12
50	80	12
40	70	12
30	90	24
20	80	24
< 20	Dose based on serum concentrations

6. Monitor:

- Obtain PEAK & TROUGH concentrations after third dose following initiation or adjustment of therapy

-- Trough concentrations should be < 2 mcg/ml

-- Avoid prolonged high peak and trough concentrations (ototoxicity, renal toxicity)

- Peak & trough levels should be measured at least every 3 - 5 days when stable.

- Measure serum creatinine with every peak & trough and at least every 3 days

- Concentrations not necessary if duration of therapy < 48 - 72 hours

7. Target peak concentrations: varies by type of infection

Site of Infection	Peak Level
Uncomplicated lower UTI	2 - 4 mcg/ml
Gram (+) endocarditis [synergy with penicillin]	4 - 5 mcg/ml
Gram (-) septicemia, other serious gram (-) infections	6 - 8 mcg/ml
Gram (-) pneumonia	8 - 10 mcg/ml

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Last updated: �7/8/1997