GENTAMICIN GUIDELINE FOR USE IN ADULTS …

1 YES NO YES NO eGFR 20ml/min eGFR <20ml/min Aminoglycoside antibiotic bactericidal against many gram-negative and some gram-positiv e organisms. NO anaerobic activ ity. See Micro Man. GENTAMICIN is monitored using the Hartford nomogram which relates observ ed concentration to the time post dose within a given concentration range. Follow separate guidance when using GENTAMICIN for Surgical Prophylaxis o r i n Endocarditis, Pregnancy, Cy s tic F ibros is, Renal Unit inpatients or patients on dialysis The dose is calculated as detailed below and repeated at 24 hour interv als or longer. STEP 1: ASSESS PATIENT SUITABILITY Does the patient have any of the following exclusion criteria?

2 Children < 16 years old Ascites > 20% body weight Major burns > 20% body surface Decompensated Liver Disease Myasthenia Gravis Renal Transplant Acute Kidney Injury (AKI 3) on dialysis or eGFR <20ml/min End stage renal failure on dialysis w ith residual kidney function Seek Advice Contact ID/Micro about alternative Doe s the patient have? Chronic Kidney Disease (eGFR 20-29ml/min) OR Acute Kidney Injury (AKI 1 or 2) in prev ious 48 hours (>50% increase in baseline serum creatinine or oliguria (<0. 5m l /k g/ h r > 6 h o u rs)) Giv e first dose then refer to ID or Microbiology to continue GENTAMICIN therapy or adv ise on alternativ e aztreonam. See guidance Maximum gentami cin course length is 72hours.

3 Rev iew IV antibiotics daily. If IV therapy is still indicated after 72 hours seek advice and consider switching to aztreonam to reduce risks of prolonged treatment w ith GENTAMICIN Ev aluate on the nomogram. If the level falls in the area designated 24 hourly, 36 hourly or 48 hourly the dosing interval should be every 24, 36, 48 hours respectively. If the point is on the line, choose the longer interval. Record AL L sample dates/times accurately ov erleaf and prescribe subsequent doses. I f a 6-14 h ou r blo od s ampl e is no t take n or i f th e bl oo d lev el fa lls ab ov e th e max imum dosi ng li ne o n the n om ogr am: take bl oo d sampl e min imum 24 h ou rs pos t dos e a nd w ait for l ev el. Only giv e dose if <1mg/ L.

4 I f 1mg/ L w ithho ld d ose a nd r ech eck in 1 2-2 4 hrs. Assess daily the ongoing need for GENTAMICIN and monitor for renal/oto toxicity. If rena l fu nction s ta ble fur th er g en tam icin l ev els no t re quir ed fo r dos es w ithi n 72 hr d ura ti on. S eek a dv ice if ren al func ti on u nstab le o r de te rio ra tes. Updated by AMG: Feb 2017 Approv ed: Feb 2017 R ev iew Date: Feb 2019 If patient receiving ID/Micro approved prolonged therapy ( >72 hours) seek advice on monitoring from clinical pharmacist or antimicrobial pharmacist - Bleep 4732. If >7days consider referral to audiology. Ensure start time of infusion and dose is documented on GENTAMICIN chart and ICE request. Take blood sample prior to printing off label 6-1 4 hours from the B EGI NNI NG of the IV infusion.

5 GENTAMICI N GUIDELINE FOR USE IN ADULTS (HARTFORD Guidance) Administer in 100ml sodium chloride or glucose 5% over 60 minutes. Ensure start time of infusion and dose is documented on GENTAMICIN chart and ICE request. Take blood sample prior to printing off label at 24 hours fr om th e B EGINN IN G of the IV infusion. Do NOT use nomo gra m if eGFR <2 0ml/mi n. If th er apy is to con ti nu e giv e a fur th er d ose once ge ntamici n lev el is <1mg/L. Recor d ALL samp le d a tes/times accur ately ov erlea f an d pr escri be subse qu en t d oses. PREFERRED METHOD: U s e online calculator (available on NHST antibiotic website or Antimicrobial Companion App) when creatinine is known. In patients with low creatinine (<60 micromol/L) use 60 micromol/L.

6 See NHST antibiotic website for GENTAMICIN chart and calculator guidance for prescribers and nursing staff. ALTERNATIVE METHOD: If creatinine is NOT k now n OR online calculator not available, calculate dose based on equations below: Determine i de al body weight of patient using national online table. Is actual weight >20% abov e their ideal body weight (IBW)? If NO eGFR 2 0m l/ m i n Dose = Actual Body Weight x 7mg (Maximum 600mg Round to nearest 40mg) ID/Micro approv ed in eGFR <20ml/min Dose = Actual Body Weight x g (Maximum dose: 180m g- Round to nearest 10mg) If YES calculate dosing weight (DW) and dose fr om equatio ns below: DW = IBW + (ABW IBW) eGFR 2 0m l/ m i n Dose = 7mg x DW (M aximum 600mg Round to nearest 40mg) ID/ M ic ro approv ed in eGFR <20ml/min Dose = DW x g (Maximum dose: 180mg- Round to nearest 10mg) Document dose calculation on the GENTAMICIN prescription chart and tick which source of first dose w as used.

7 Prescribe initial dose on the GENTAMICIN chart specify ing the date and time the dose should be given. Stick the GENTAMICIN chart to the as required page on the TPAR so the red band is clearly v isible when TPAR closed. Prescribe GENTAMICIN as per chart on the regular section of the T P AR. STEP 2: CALCUL AT E DOS E s eek advice on calculation for patients at e xtremes of age /he ight/we ight or if am p utee STEP 3: M ONITOR RENAL FUNCTION, G ENTAMICIN L EV ELS AND DET ERMI NE DOSI NG INT ERVAL