Gentamicin Dosage

Drug Detail:Gentamicin (systemic) (monograph) (Medically reviewed)

Drug Class:

Usual Adult Dose for Osteomyelitis

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Life-threatening infections:
Initial dose: 5 mg/kg IM or IV infusion (over 30 to 120 minutes) per day, given in divided doses 3 to 4 times a day
Maintenance dose: 3 mg/kg IM or IV infusion (over 30 to 120 minutes) per day, given in divided doses 3 to 4 times a day
Duration of therapy: 7 to 10 days

Comments:

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Skin or Soft Tissue Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Bacterial Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Urinary Tract Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Sepsis

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Burns - External

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Comments:

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial septicemia caused by susceptible strains of Pseudomonas aeruginosa, Proteus species (indole-positive/-negative), Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Some experts recommend:
Sepsis: 5 to 7 mg/kg IM or IV every 24 hours

Duration of therapy: 7 to 10 days

Comments:

Optimal antimicrobial treatment may require the addition of antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.
A longer duration of therapy should be considered in patients with bacteremia with Staphylococcus aureus, immunologic deficiencies (e.g., neutropenia), a slow clinical response, some fungal/viral infections, and/or undrainable foci of infection.

Use: Treatment of sepsis and septic shock

Usual Adult Dose for Endocarditis

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Use: Treatment of endocarditis (with a penicillin-type agent) caused by group D streptococci

American Heart Association (AHA) and Infectious Diseases Society of America (IDSA) Recommendations:
Empiric Treatment and culture-negative endocarditis:
Native-valve (community-acquired) OR "late" prosthetic valve: 3 to 5 mg/kg IV per day PLUS ampicillin/sulbactam with/without vancomycin

Enterococcal endocarditis: 3 to 5 mg/kg IM or IV per day, given in 2 to 3 equally divided doses PLUS penicillin G OR ampicillin

Duration of therapy: 4 to 6 weeks

Gram-negative enteric bacilli: 3 to 5 mg/kg IV per day (or tobramycin or amikacin) PLUS ceftazidime, cefepime, cefotaxime, or ceftriaxone

Duration of therapy: At least 6 weeks

Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species (HACEK group): 3 to 5 mg/kg IV per day (or tobramycin or amikacin) PLUS ampicillin

Duration of therapy: 4 to 6 weeks

Staphylococcal endocarditis: 3 to 5 mg/kg IM or IV per day, given in 2 to 3 doses PLUS rifampin AND nafcillin or oxacillin OR vancomycin

Duration of therapy: 2 weeks
Some experts state 3 to 5 days in patients unable to tolerate beta-lactam antibiotics.

Viridians group Streptococcus (VGS): 3 to 5 mg/kg IM or IV every 24 hours PLUS penicillin G or ceftriaxone
Duration of therapy:

Native valve endocarditis: 2 weeks
Prosthetic valve endocarditis with a penicillin-susceptible strain (minimum inhibitory concentration [MIC] of 0.12 mcg/mL or less): 2 weeks
Prosthetic valve endocarditis with a penicillin relatively/fully resistant strain (MIC greater than 0.12 mcg/mL): 6 weeks

Comments:

Rifampin should be added to empiric treatment with prosthetic valve infections.
"Late" infections typically occurred 1 year or later after surgery.
The dose may be given in 3 equally divided doses per day.
Less susceptible isolates may require the substitution of ampicillin for penicillin G.
Patients with enterococcal endocarditis should be given evenly divided doses every 8 hours.
Some experts state that vancomycin should be given with enterococcal infections.

Uses:

Empiric or culture-negative infective endocarditis (IE) treatment of community-acquired native valve or late prosthetic valve IE
Treatment of uncomplicated IE caused by highly penicillin-susceptible (MIC less than 0.12 mcg/mL) VGS or Streptococcus gallolyticus (bovis)
Treatment of uncomplicated IE caused by relatively penicillin-resistant (MIC between 0.12 and 0.5 mcg/mL) VGS and S gallolyticus (bovis)
Treatment of uncomplicated IE caused by Abiotrophia defectiva, Granulicatella species, and penicillin-resistant VGS (MIC 0.5 mcg/mL and greater)
Treatment of endocarditis involving a prosthetic valve or other prosthetic material caused by VGS and S gallolyticus (bovis)
Treatment of IE involving a prosthetic valve or other prosthetic material caused by group B, C, or G streptococci
Treatment of IE involving a prosthetic valve or other prosthetic material caused by oxacillin-susceptible and -resistant staphylococci
Treatment of IE involving a native or prosthetic valve or other prosthetic material resulting from Enterococcus species
Recommended antibiotic treatment (in conjunction with penicillin G or ampicillin) of IE caused by strains that are relatively resistant to penicillin (minimum bacterial concentration [MBC] greater than or equal to 0.2 mcg/mL), including enterococci, and less-susceptible viridans streptococci
Alternative antibiotic treatment (in conjunction ceftriaxone and/or vancomycin) of IE caused by strains that are relatively resistant to penicillin (MBC greater than or equal to 0.2 mcg/mL), including enterococci, and less-susceptible viridans streptococci
Recommended antibiotic treatment (with oxacillin or nafcillin) for the treatment of IE caused by Staphylococcus aureus or coagulase-negative staphylococci resistant to 0.1 mcg/mL penicillin G
Recommended antibiotic treatment (with ceftazidime, cefepime, cefotaxime, or ceftriaxone) for the treatment of IE caused by gram-negative enteric bacilli
Alternative antibiotic treatment (with piperacillin/tazobactam) for the treatment of IE caused by gram-negative enteric bacilli
Alternative antibiotic treatment (with ampicillin) for the treatment of IE caused by HACEK group organisms

IDSA Recommendations:
Prosthetic valve endocarditis: 1 mg/kg IV every 8 hours with vancomycin and rifampin
Duration of therapy: 2 weeks

Comments:

Early evaluation for valve replacement surgery should be considered.
Vancomycin and rifampin should be continued for at least 4 weeks for a total duration of therapy of at least 6 weeks.

Use: Treatment of prosthetic valve endocarditis caused by methicillin-resistant S aureus (MRSA)

Usual Adult Dose for Meningitis

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Use: Treatment of central nervous system infections, including meningitis, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

IDSA, American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
Healthcare-Associated Ventriculitis and Meningitis:
IV: 5 mg/kg IV per day, given in divided doses every 8 hours
Intraventricular:
Patients with slit ventricles: 2 mg via intraventricular route (plus vancomycin)
Patients with normal-sized ventricles: 3 mg via intraventricular route (plus vancomycin)
Patients with enlarged ventricles: 4 to 5 mg via intraventricular route (plus vancomycin)

Intraventricular route frequency of dosing:

External drain output less than 50 mL/day: every 3 days
External drain output 50 to 100 mL/day: every 2 days
External drain output 100 to 150 mL/day: once a day
External drain output 150 to 200 mL/day: increase the dose by 1 mg (plus vancomycin) and give once a day
External drain output 200 to 250 mL/day: increase the dose by 2 mg (plus vancomycin) and give once a day

Duration of therapy:

Neisseria meningitis or Haemophilus influenzae: 7 days
Coagulase-negative staphylococcus or Propionibacterium acnes with no/minimal cerebrospinal fluid (CSF) pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, Staphylococcus aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
Streptococcus pneumoniae: 10 to 14 days
Streptococcus agalactiae: 14 to 21 days
Aerobic gram-negative bacilli: 21 days
Listeria monocytogenes: At least 21 days
Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Comments:

The usual intraventricular dose was 4 to 8 mg/day.
The intraventricular drain should be clamped for approximately 15 to 60 minutes to allow the drug to equilibrate.

Use: Treatment of healthcare-associated ventriculitis and meningitis

Usual Adult Dose for CNS Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

External drain output less than 50 mL/day: every 3 days
External drain output 50 to 100 mL/day: every 2 days
External drain output 100 to 150 mL/day: once a day
External drain output 150 to 200 mL/day: increase the dose by 1 mg (plus vancomycin) and give once a day
External drain output 200 to 250 mL/day: increase the dose by 2 mg (plus vancomycin) and give once a day

Duration of therapy:

Neisseria meningitis or Haemophilus influenzae: 7 days
Coagulase-negative staphylococcus or Propionibacterium acnes with no/minimal cerebrospinal fluid (CSF) pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, Staphylococcus aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
Streptococcus pneumoniae: 10 to 14 days
Streptococcus agalactiae: 14 to 21 days
Aerobic gram-negative bacilli: 21 days
Listeria monocytogenes: At least 21 days
Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Comments:

The usual intraventricular dose was 4 to 8 mg/day.
The intraventricular drain should be clamped for approximately 15 to 60 minutes to allow the drug to equilibrate.

Use: Treatment of healthcare-associated ventriculitis and meningitis

Usual Adult Dose for Intraabdominal Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Use: Treatment of serious bacterial infections of the gastrointestinal tract caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

Surgical Infection Society (SIS) and IDSA Recommendations:
Initial dose: 5 to 7 mg/kg IV every 24 hours
Duration of therapy: Up to 4 to 7 days

Comments:

This drug should be used in combination with a carbapenem and piperacillin-tazobactam in healthcare-associated infections.
Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated healthcare-associated intraabdominal infections caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae or P aeruginosa greater than 20% resistant to ceftazidime

Usual Adult Dose for Peritonitis

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Use: Treatment of peritonitis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

International Society for Peritoneal Dialysis (ISPD) Recommendations:
Intermittent (1 exchange daily): 0.6 mg/kg intraperitoneally once a day

Continuous (all exchanges):

Loading dose: 8 mg/L
Maintenance dose: 4 mg/L

Comments:

Intermittent dosing is recommended, and should be allowed to dwell for at least 6 hours.
Prolonged courses of treatment should be avoided.

Use: Treatment of peritonitis

Usual Adult Dose for Pneumonia

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of serious bacterial infections of the respiratory tract caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative respiratory tract infections
Treatment of serious respiratory tract infections where the causative organisms are unknown

IDSA and American Thoracic Society (ATS) Recommendations:
Duration of therapy: At least 5 days

Comments:

This drug should be given with an antipseudomonal beta-lactam antibiotic or cipro-/levofloxacin when treating infections caused by P aeruginosa.
Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Use: Preferred adjunctive treatment of community-acquired pneumonia caused by P aeruginosa

Usual Adult Dose for Upper Respiratory Tract Infection

Systemic infections: 1 mg/kg IM or IV infusion (over 30 to 120 minutes) every 8 hours

Duration of therapy: 7 to 10 days

Additional antimicrobial therapy should be added if anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of serious bacterial infections of the respiratory tract caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative respiratory tract infections
Treatment of serious respiratory tract infections where the causative organisms are unknown

IDSA and American Thoracic Society (ATS) Recommendations:
Duration of therapy: At least 5 days

Comments:

This drug should be given with an antipseudomonal beta-lactam antibiotic or cipro-/levofloxacin when treating infections caused by P aeruginosa.
Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Use: Preferred adjunctive treatment of community-acquired pneumonia caused by P aeruginosa

Usual Adult Dose for Bacteremia

IDSA Recommendations:
Persistent bacteremia: 1 mg/kg IV every 8 hours PLUS high-dose daptomycin

Comment: Search and removal of other foci of infection, drainage, or surgical debridement should be performed.

Use: Management of persistent MRSA bacteremia and vancomycin treatment failures

Usual Adult Dose for Surgical Prophylaxis

American Society of Health-System Pharmacists (ASHP), IDSA, Society for Healthcare Epidemiology of America (SHEA), and SIS Recommendations:
5 mg/kg IV once, within 120 minutes before surgery

Comment: The recommended redosing interval from initiation of the preoperative dose is 2 hours.

Uses:
Recommended agent (in combination with cefazolin) for surgical prophylaxis in patient undergoing:

Some urologic procedures (e.g., clean with/without entry into urinary tract [placement of prosthetic material, such as penile prosthesis], involving implanted prostheses)

Alternative agent for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:

Some urologic procedures (e.g., lower tract instrumentation with risk factors for infection [including transrectal prostate biopsy])

Alternative agent (in combination with clindamycin, vancomycin, metronidazole, aztreonam, or a fluoroquinolone) for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:

Appendectomy for uncomplicated appendicitis
Cesarean delivery
Colorectal
Gastroduodenal procedures (e.g., procedures involving entry in to the lumen of the gastrointestinal tract, elective, high-risk laparoscopic procedures, or procedures not entering the GI tract in high-risk patients)
Hysterectomy (vaginal/abdominal)
Small intestine (e.g., nonobstructed, obstructed)
Some urologic procedures (e.g., clean surgery involving implanted prosthesis, clean without entry into urinary tract, clean-contaminated with entry into urinary tract)
Transplantation procedures (e.g., heart-lung transplantation, liver transplantation, pancreas transplantation, pancreas-kidney transplantation)

Usual Adult Dose for Pelvic Inflammatory Disease

US Centers for Disease Control and Prevention (US CDC) Recommendations:
Parenteral Treatment:
Initial dose: 2 mg/kg IM or IV once
Maintenance dose: 1.5 mg/kg IM or IV every 8 hours OR 3 to 5 mg/kg once a day

Comments:

This drug should be given with IV cefotetan, doxycycline OR cefoxitin, and doxycycline OR clindamycin.
At least 24 hours of inpatient observation is recommended for patients with tubo-ovarian abscesses.
Daily doses have not been evaluated for treatment of this condition; however, it has been efficacious in analogous conditions.
Oral therapy may be initiated within 24 to 28 hours of clinical improvement.

Use: Recommended adjunctive treatment of pelvic inflammatory disease due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma hominis

Usual Adult Dose for Plague

IDSA and ATS Recommendations:
1.5 mg/kg IM every 8 hours

Duration of therapy: Up to 14 days

Comments:

Due to health risks posed to laboratory personnel, the laboratory should be notified when tularemia is suspected.
This drug should be given with an antipseudomonal beta-lactam antibiotic or cipro-/levofloxacin when treating infections caused by P aeruginosa.
Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
This drug may be substituted for streptomycin in the treatment of bubonic plague.
Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Uses:

Treatment of severe tularemia caused by Francisella tularensis
Alternative treatment of bubonic plague caused by Yersinia pestis
Alternative treatment of community-acquired pneumonia caused by F tularensis
Preferred adjunctive treatment of community-acquired pneumonia caused by Y pestis

Usual Adult Dose for Tularemia

IDSA and ATS Recommendations:
1.5 mg/kg IM every 8 hours

Duration of therapy: Up to 14 days

Comments:

Due to health risks posed to laboratory personnel, the laboratory should be notified when tularemia is suspected.
This drug should be given with an antipseudomonal beta-lactam antibiotic or cipro-/levofloxacin when treating infections caused by P aeruginosa.
Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
This drug may be substituted for streptomycin in the treatment of bubonic plague.
Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Uses:

Treatment of severe tularemia caused by Francisella tularensis
Alternative treatment of bubonic plague caused by Yersinia pestis
Alternative treatment of community-acquired pneumonia caused by F tularensis
Preferred adjunctive treatment of community-acquired pneumonia caused by Y pestis

Usual Adult Dose for Bartonellosis

US Department of Health and Human Services (US HHS), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), and US CDC Recommendations:
1 mg/kg IV every 8 hours PLUS doxycycline

Duration of therapy: 2 weeks

Comment: After 2 weeks, IV or oral doxycycline should be continued for at least 3 months total.

Use: Treatment of confirmed Bartonella endocarditis

AHA Recommendations:
Suspected Bartonella endocarditis, culture negative or initially culture negative: 3 mg/kg IM or IV per day, given in 3 equally divided doses

Duration of therapy: 2 weeks

Comments:

Doxycycline should be continued for an additional 4 weeks.
Patients should be treated in consultation with an infectious disease specialist.

Uses:

Treatment of suspected Bartonella endocarditis (in conjunction with ceftriaxone with/without doxycycline), culture negative
Treatment of documented Bartonella infection (with doxycycline), initially culture negative, determined to be positive by nonculture tests

Usual Pediatric Dose for Osteomyelitis

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

American Academy of Pediatrics (AAP) Recommendations:
Gestational age less than 30 weeks, postnatal age 14 days or less: 5 mg/kg IM or IV every 48 hours
Gestational age less than 30 weeks, postnatal age over 14 days: 5 mg/kg IM or IV every 36 hours
Gestational age 30 to 34 weeks, postnatal age 14 days or less: 5 mg/kg IM or IV every 36 hours
Gestational age 30 to 34 weeks, postnatal age over 14 days: 5 mg/kg IM or IV every 24 hours
Gestational age 35 weeks or greater, postnatal age 7 days or less: 4 mg/kg IM or IV every 24 hours
Gestational age 35 weeks or greater, postnatal age over 7 days: 5 mg/kg IM or IV every 24 hours
Greater than 28 days: 6 to 7.5 mg IM or IV in 3 doses OR 5 to 7.5 mg IM or IV once a day

Comments:

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Skin or Soft Tissue Infection

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Upper Respiratory Tract Infection

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Bacterial Infection

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Urinary Tract Infection

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Sepsis

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Burns - External

This drug is not routinely indicated in the initial treatment of uncomplicated urinary tract infections UNLESS the organism is resistant to other less toxic antibacterial agents.
Empiric treatment may begin prior to obtaining susceptibility results.
Additional antimicrobial therapy should be added is anaerobic organisms are suspected.
Maintenance doses should be used as soon as clinically indicated.

Uses:

Treatment of bacterial neonatal sepsis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of bacterial septicemia caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Treatment of serious bacterial infections of the bone, burns, respiratory tract, skin, soft tissue, and urinary tract, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)
Empiric treatment in suspected/confirmed gram-negative infections
Treatment of serious infections where the causative organisms are unknown
Treatment of life-threatening infections (with carbenicillin) caused by P aeruginosa
Alternative empiric treatment option for serious staphylococcal infections in patients where penicillins or other less potentially toxic drugs are contraindicated and bacterial susceptibility tests and clinical judgment indicate its use
Treatment of mixed infections caused by susceptible strains of staphylococci and gram-negative organisms

Serum concentrations should guide ongoing treatment.
Higher doses should be used to treat severe infections.

Usual Pediatric Dose for Endocarditis

Premature and full-term neonates 1 week of age or less: 2.5 mg/kg IM or IV every 12 hours
Neonates and infants: 2.5 mg/kg IM or IV every 8 hours
Children: 2 to 2.5 mg/kg IM or IV every 8 hours
Duration of therapy: 7 to 10 days

Use: Treatment of endocarditis (with a penicillin-type agent) caused by group D streptococci

AHA and IDSA Recommendations:
Children:
Empiric treatment and culture-negative endocarditis:
Native-valve (community-acquired) OR "late" prosthetic valve: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours PLUS ampicillin/sulbactam with/without vancomycin

Enterococcal endocarditis: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours PLUS penicillin G OR ampicillin

Duration of therapy: 4 to 6 weeks

Gram-negative enteric bacilli endocarditis: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours (or tobramycin or amikacin) PLUS ceftazidime, cefepime, cefotaxime, or ceftriaxone

Duration of therapy: At least 6 weeks

HACEK group endocarditis: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours (or tobramycin or amikacin) PLUS ampicillin)

Duration of therapy: 4 to 6 weeks

Staphylococcal endocarditis: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours doses PLUS rifampin AND nafcillin or oxacillin OR vancomycin

Duration of therapy: 2 weeks
Some experts state 3 to 5 days in patients unable to tolerate beta-lactam antibiotics.

VGS endocarditis: 3 to 6 mg/kg IV per day, given in divided doses every 8 hours PLUS penicillin G or ceftriaxone
Duration of therapy:

Native valve endocarditis: 2 weeks
Prosthetic valve endocarditis with a penicillin-susceptible strain (MIC of 0.12 mcg/mL or less): 2 weeks
Prosthetic valve endocarditis with a penicillin relatively/fully resistant strain (MIC greater than 0.12 mcg/mL): 6 weeks

Comments:

Rifampin should be added to empiric treatment with prosthetic valve infections.
"Late" infections typically occurred 1 year or later after surgery.
The dose may be given in 3 equally divided doses per day.
Less susceptible isolates may require the substitution of ampicillin for penicillin G.
Some experts state that vancomycin should be given with enterococcal infections.

Uses:

Empiric or culture-negative IE treatment of community-acquired native valve or late prosthetic valve IE
Treatment of uncomplicated IE caused by highly penicillin-susceptible (MIC less than 0.12 mcg/mL) VGS or S gallolyticus (bovis)
Treatment of uncomplicated IE caused by relatively penicillin-resistant (MIC between 0.12 and 0.5 mcg/mL) VGS and S gallolyticus (bovis)
Treatment of uncomplicated IE caused by A defectiva, Granulicatella species, and penicillin-resistant VGS (MIC 0.5 mcg/mL and greater)
Treatment of IE involving a prosthetic valve or other prosthetic material caused by VGS and S gallolyticus (bovis)
Treatment of IE involving a prosthetic valve or other prosthetic material caused by group B, C, or G streptococci
Treatment of IE involving a prosthetic valve or other prosthetic material caused by oxacillin-susceptible and -resistant staphylococci
Treatment of IE involving a native or prosthetic valve or other prosthetic material resulting from Enterococcus species
Recommended antibiotic treatment (in conjunction with penicillin G or ampicillin) of IE caused by strains that are relatively resistant to penicillin (MBC greater than or equal to 0.2 mcg/mL), including enterococci, and less-susceptible viridans streptococci
Alternative antibiotic treatment (in conjunction ceftriaxone and/or vancomycin) of IE caused by strains that are relatively resistant to penicillin (MBC greater than or equal to 0.2 mcg/mL), including enterococci, and less-susceptible viridans streptococci
Recommended antibiotic treatment (with oxacillin or nafcillin) for the treatment of IE caused by S aureus or coagulase-negative staphylococci resistant to 0.1 mcg/mL penicillin G
Recommended antibiotic treatment (with ceftazidime, cefepime, cefotaxime, or ceftriaxone) for the treatment of IE caused by gram-negative enteric bacilli
Alternative antibiotic treatment (with piperacillin/tazobactam) for the treatment of IE caused by gram-negative enteric bacilli
Alternative antibiotic treatment (with ampicillin) for the treatment of IE caused by HACEK group organisms

IDSA Recommendations:
Children:
Prosthetic valve endocarditis: 1 mg/kg IV every 8 hours with vancomycin and rifampin

Duration of therapy: 2 weeks

Comments:

Early evaluation for valve replacement surgery should be considered.
Vancomycin and rifampin should be continued for at least 4 weeks for a total duration of therapy of at least 6 weeks.

Use: Treatment of prosthetic valve endocarditis caused by MRSA

Usual Pediatric Dose for Meningitis

Premature and full-term neonates 1 week of age or less: 2.5 mg/kg IM or IV every 12 hours
Neonates and infants: 2.5 mg/kg IM or IV every 8 hours
Children: 2 to 2.5 mg/kg IM or IV every 8 hours
Duration of therapy: 7 to 10 days

Use: Treatment of central nervous system infections, including meningitis, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

IDSA, AAN, AANS, and NCS Recommendations:
Bacterial Meningitis:
Neonates 0 to 7 days: 5 mg/kg IV per day, given in divided doses every 12 hours
Neonates 8 to 28 days, infants, and children: 7.5 mg/kg IV per day, given in divided doses every 8 hours

Healthcare-Associated Ventriculitis and Meningitis:
Infants and children:
IV: 7.5 mg/kg IV per day, given in divided doses every 8 hours
Intraventricular:

Patients with slit ventricles: 2 mg via intraventricular route (plus vancomycin)
Patients with normal-sized ventricles: 3 mg via intraventricular route (plus vancomycin)
Patients with enlarged ventricles: 4 to 5 mg via intraventricular route (plus vancomycin)

Intraventricular route frequency of dosing:

External drain output less than 50 mL/day: every 3 days
External drain output 50 to 100 mL/day: every 2 days
External drain output 100 to 150 mL/day: once a day
External drain output 150 to 200 mL/day: increase the dose by 1 mg (plus vancomycin) and give once a day
External drain output 200 to 250 mL/day: increase the dose by 2 mg (plus vancomycin) and give once a day

Duration of therapy:

N meningitis or H influenzae: 7 days
Coagulase-negative Staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
S pneumoniae: 10 to 14 days
S agalactiae: 14 to 21 days
Aerobic gram-negative bacilli: 21 days
L monocytogenes: At least 21 days
Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Comments:

The usual intraventricular dose was 1 to 2 mg/day.
The intraventricular drain should be clamped for approximately 15 to 60 minutes to allow the drug to equilibrate.
Neonate duration of therapy is 2 weeks beyond the first sterile CSF culture OR at least 3 weeks, whichever is longer.

Use: Treatment of healthcare-associated ventriculitis and meningitis

Usual Pediatric Dose for CNS Infection

Premature and full-term neonates 1 week of age or less: 2.5 mg/kg IM or IV every 12 hours
Neonates and infants: 2.5 mg/kg IM or IV every 8 hours
Children: 2 to 2.5 mg/kg IM or IV every 8 hours
Duration of therapy: 7 to 10 days

Use: Treatment of central nervous system infections, including meningitis, caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

IDSA, AAN, AANS, and NCS Recommendations:
Bacterial Meningitis:
Neonates 0 to 7 days: 5 mg/kg IV per day, given in divided doses every 12 hours
Neonates 8 to 28 days, infants, and children: 7.5 mg/kg IV per day, given in divided doses every 8 hours

Healthcare-Associated Ventriculitis and Meningitis:
Infants and children:
IV: 7.5 mg/kg IV per day, given in divided doses every 8 hours
Intraventricular:

Patients with slit ventricles: 2 mg via intraventricular route (plus vancomycin)
Patients with normal-sized ventricles: 3 mg via intraventricular route (plus vancomycin)
Patients with enlarged ventricles: 4 to 5 mg via intraventricular route (plus vancomycin)

Intraventricular route frequency of dosing:

External drain output less than 50 mL/day: every 3 days
External drain output 50 to 100 mL/day: every 2 days
External drain output 100 to 150 mL/day: once a day
External drain output 150 to 200 mL/day: increase the dose by 1 mg (plus vancomycin) and give once a day
External drain output 200 to 250 mL/day: increase the dose by 2 mg (plus vancomycin) and give once a day

Duration of therapy:

N meningitis or H influenzae: 7 days
Coagulase-negative Staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
S pneumoniae: 10 to 14 days
S agalactiae: 14 to 21 days
Aerobic gram-negative bacilli: 21 days
L monocytogenes: At least 21 days
Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Comments:

The usual intraventricular dose was 1 to 2 mg/day.
The intraventricular drain should be clamped for approximately 15 to 60 minutes to allow the drug to equilibrate.
Neonate duration of therapy is 2 weeks beyond the first sterile CSF culture OR at least 3 weeks, whichever is longer.

Use: Treatment of healthcare-associated ventriculitis and meningitis

Usual Pediatric Dose for Intraabdominal Infection

Premature and full-term neonates 1 week of age or less: 2.5 mg/kg IM or IV every 12 hours
Neonates and infants: 2.5 mg/kg IM or IV every 8 hours
Children: 2 to 2.5 mg/kg IM or IV every 8 hours
Duration of therapy: 7 to 10 days

Use: Treatment of serious bacterial infections of the gastrointestinal tract caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

AAP Recommendations:
Neonatal (over 72 hours) and children: 2 mg/kg IM or IV PLUS cefoxitin OR 2.5 mg/kg IM or IV PLUS metronidazole once

Use: Treatment of ruptured viscus caused by enteric gram-negative bacilli, enterococci, and/or anaerobes (Bacteroides species)

SIS and IDSA Recommendations:
Initial dose: 3 to 7.5 mg/kg IV, given in divided doses every 2 to 4 hours

Duration of therapy: Up to 4 to 7 days

Comments:

This drug may be used in combination with metronidazole or clindamycin with/without ampicillin in community-acquired infections.
This drug should be used in combination with a carbapenem and piperacillin-tazobactam in healthcare-associated infections.
Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Uses:

Empiric combination treatment of extra-biliary complicated intraabdominal community-acquired infection
Empiric combination treatment of complicated healthcare-associated intraabdominal infections caused by ESBL-producing Enterobacteriaceae or P aeruginosa greater than 20% resistant to ceftazidime
Alternative treatment in patients with severe reactions to beta-lactam antibiotics
Adjunctive treatment of necrotizing enterocolitis in neonates

Usual Pediatric Dose for Peritonitis

Premature and full-term neonates 1 week of age or less: 2.5 mg/kg IM or IV every 12 hours
Neonates and infants: 2.5 mg/kg IM or IV every 8 hours
Children: 2 to 2.5 mg/kg IM or IV every 8 hours
Duration of therapy: 7 to 10 days

Use: Treatment of peritonitis caused by susceptible strains of P aeruginosa, Proteus species (indole-positive/-negative), E coli, Klebsiella-Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species (coagulase-positive/-negative)

ISPD Recommendations:
Continuous peritoneal dialysis:

Loading dose: 8 mg/L
Maintenance dose: 4 mg/L

Intermittent peritoneal dialysis:

Anuric patients: 0.6 mg/kg intraperitoneally once a day
Non-anuric patients: 0.75 mg/kg intraperitoneally once a day

Comments:

Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
Prolonged courses of treatment should be avoided.

Use: Treatment of peritonitis

Usual Pediatric Dose for Surgical Prophylaxis

AAP Recommendations:
Neonatal (72 hours or less): 2.5 mg/kg IM or IV once PLUS ampicillin
Neonatal (over 72 hours) and children:

Colorectal or appendectomy: 2.5 mg/kg IM or IV once PLUS cefoxitin or metronidazole OR 2.5 mg/kg IM or IV once PLUS cefazolin PLUS metronidazole or clindamycin
Genitourinary: 2 mg/kg IM or IV once PLUS ampicillin
Head and neck: 2.5 mg/kg IM or IV once PLUS metronidazole with/without clindamycin

Uses:

Preoperative antimicrobial prophylaxis in neonatal patients 72 hours or younger in age with the following likely pathogens: Group B streptococci, enteric gram-negative bacilli, enterococci, coagulase-negative staphylococci
Preoperative antimicrobial prophylaxis in neonatal patients older than 72 hours and children undergoing uncomplicated, nonperforated colorectal or appendectomy with the following likely pathogens: enteric gram-negative bacilli, enterococci, and/or anaerobes (Bacteroides species)
Preoperative antimicrobial prophylaxis in neonatal patients older than 72 hours and children undergoing genitourinary procedures with the following likely pathogens: enteric gram-negative bacilli and enterococci
Preoperative antimicrobial prophylaxis in neonatal patients older than 72 hours and children undergoing head and neck surgery (incision through oral/pharyngeal mucosa) with the following likely pathogens: anaerobes, enteric gram-negative bacilli, S aureus

ASHP, IDSA, SHEA, and SIS Recommendations:
1 year and older: 2.5 mg/kg IV once, within 120 minutes before surgery

Comment: The recommended redosing interval from initiation of the preoperative dose is 2 hours.

Uses:
Recommended agent (in combination with cefazolin) for surgical prophylaxis in patient undergoing:

Some urologic procedures (e.g., clean with/without entry into urinary tract [placement of prosthetic material, such as penile prosthesis], involving implanted prostheses)

Alternative agent for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:

Some urologic procedures (e.g., lower tract instrumentation with risk factors for infection [including transrectal prostate biopsy])

Appendectomy for uncomplicated appendicitis
Cesarean delivery
Colorectal
Gastroduodenal procedures (e.g., procedures involving entry in to the lumen of the gastrointestinal tract, elective, high-risk laparoscopic procedures, or procedures not entering the GI tract in high-risk patients)
Hysterectomy (vaginal/abdominal)
Small intestine (e.g., nonobstructed, obstructed)
Some urologic procedures (e.g., clean surgery involving implanted prosthesis, clean without entry into urinary tract, clean-contaminated with entry into urinary tract)
Transplantation procedures (e.g., heart-lung transplantation, liver transplantation, pancreas transplantation, pancreas-kidney transplantation)

Usual Pediatric Dose for Pelvic Inflammatory Disease

US CDC and AAP Recommendations:
Adolescents:
Parenteral Regimen:
Loading dose: 2 mg/kg IM or IV once
Maintenance dose: 1.5 mg/kg IM or IV every 8 hours OR 3 to 5 mg/kg once a day

Comments:

This drug should be given with IV cefotetan, doxycycline OR cefoxitin, and doxycycline OR clindamycin.
At least 24 hours of inpatient observation is recommended for patients with tubo-ovarian abscesses.
Daily doses have not been evaluated for treatment of this condition; however, it has been efficacious in analogous conditions.
Oral therapy may be initiated within 24 to 28 hours of clinical improvement, and should be continued to complete a total of 14 days of therapy.

Use: Recommended adjunctive treatment of pelvic inflammatory disease due to C trachomatis, N gonorrhoeae, or M hominis

Usual Pediatric Dose for Tularemia

IDSA Recommendations:
Children: 6 mg/kg IV per day, given in 3 divided doses

Duration of therapy: Up to 14 days

Comment: Due to health risks posed to laboratory personnel, the laboratory should be notified when tularemia is suspected.

Use: Treatment of severe tularemia caused by F tularensis

Usual Pediatric Dose for Bartonellosis

AHA Recommendations:
Suspected Bartonella endocarditis, culture negative or initially culture negative: 3 mg/kg IM or IV per day, given in 3 equally divided doses

Duration of therapy: 2 weeks

Comments:

Doxycycline should be continued for an additional 4 weeks.
Patients should be treated in consultation with an infectious disease specialist.

Uses:

Treatment of suspected Bartonella endocarditis (in conjunction with ceftriaxone with/without doxycycline), culture negative
Treatment of documented Bartonella infection (with doxycycline), initially culture negative, determined to be positive by nonculture tests

Renal Dose Adjustments

Known/suspected renal dysfunction: Frequent monitoring recommended.

Parenteral Administration:

Prolonged intervals (serum creatinine known): Administer the recommended single dose (e.g., 1 mg/kg IM or IV) at the dosage interval determined by multiplying the serum creatinine by 8
Reduced dose (serious systemic infections):
Administer usual loading dose (e.g., 1 mg/kg IM or IV)
Maintenance dose given IM or IV every 8 hours: (recommended dose [in mg] divided by the serum creatinine level)

Signs/symptoms of renal irritation occurring during treatment (e.g., casts, white/red cells, albumin): Increase hydration.
Evidence of renal dysfunction occurring during treatment (e.g., decreased creatinine clearance, decreased urine specific gravity, increased blood urea nitrogen/creatinine, oliguria): Dose reductions should be considered; closely monitor renal and eighth nerve function.
Increased azotemia OR a progressive decrease in urinary output occurring during treatment: Stop treatment.
Evidence of nephrotoxicity: Discontinue the drug OR adjust the dose.

Some experts recommend:
Sepsis and septic shock:

Mild renal dysfunction: No dose adjustment recommended; the dose should be given on an extended frequency (e.g., up to 3 days) before the next dose
Moderate renal dysfunction: Data not available
Severe renal dysfunction: Not recommended.

Comments:

Optimal antimicrobial treatment may require the addition of other antibiotic agents.
Patients should undergo therapeutic drug monitoring during treatment.

Use: Treatment of sepsis and septic shock

Liver Dose Adjustments

Data not available

Dose Adjustments

Therapeutic drug monitoring/range:

Peak levels (30 to 60 minutes after administration): 3 to 6 mcg/mL
Trough levels: Less than 2 mcg/mL

Obese patients: Use lean body mass to calculate dosing. Providers should consider limiting treatment to short-term durations.

Treatment exceeding 10 days: Auditory, renal, and vestibular functions should be monitored.

AHA and IDSA Recommendations:
Adults:
Enterococcal Endocarditis Therapeutic drug monitoring/range:

Peak levels (1-hour serum concentration): 3 mcg/mL
Trough levels: Less than 1 mcg/mL

Pediatric Patients:
Gram-negative rod isolates:

Peak levels: 5 to 10 mcg/mL
Trough levels: Less than 1 to 1.5 mcg/mL

Synergy:
Initial dose: 3 to 6 mg/kg per day IM or IV, given in divided doses every 8 hours
Maintenance dose: Doses adjusted to peak and trough levels

Peak levels: 3 to 4 mcg/mL
Trough levels: Less than 1 mcg/mL

ASHP, IDSA, SHEA, and SIS Recommendations:

Dosing should be determined by the patient's actual body weight.
If the patient's actual weight is 20% greater than the ideal body weight (IBW), the dosing weight should be determined by the following: IBW plus 0.4(actual weight minus IBW).

Precautions

US BOXED WARNINGS:
TOXICITY:

Patients treated with aminoglycosides should be under close clinical observation because of the potential toxicity associated with their use.
Other factors which may increase patient risk of toxicity are advanced age and dehydration.

NEPHROTOXICITY:

As with other aminoglycosides, this drug is potentially nephrotoxic. The risk of nephrotoxicity is greater in patients with impaired renal function and in those who receive high dosage or prolonged therapy.

NEUROTOXICITY:

Neurotoxicity manifested by ototoxicity, both vestibular and auditory, can occur in patients treated with this drug, primarily with pre-existing renal damage and in patients with normal renal function treated with higher doses and/or for longer periods than recommended.
Aminoglycoside-induced ototoxicity is usually irreversible.
Other manifestations of neurotoxicity may include numbness, skin tingling, muscle twitching and convulsions.

MONITORING:

Renal and eighth cranial nerve function should be closely monitored, especially in patients with known or suspected reduced renal function at onset of therapy and also in those whose renal function is initially normal but who develop signs of renal dysfunction during therapy.
Urine should be examined for decreased specific gravity, increased excretion of protein, and the presence of cells or casts.
Blood urea nitrogen (BUN), serum creatinine, or creatinine clearance should be determined periodically.
When feasible, it is recommended that serial audiograms be obtained in patients old enough to be tested, particularly high-risk patients.
Evidence of ototoxicity (dizziness, vertigo, tinnitus, roaring in the ears or hearing loss) or nephrotoxicity requires dosage adjustment or discontinuance of the drug.
As with the other aminoglycosides, on rare occasions changes in renal and eighth cranial nerve function may not become manifest until soon after completion of therapy.
Serum concentrations of aminoglycosides should be monitored when feasible to assure adequate levels and to avoid potentially toxic levels.
When monitoring peak concentrations, dosage should be adjusted so that prolonged levels above 12 mcg/mL are avoided.
When monitoring trough concentrations, dosage should be adjusted so that levels above 2 mcg/mL are avoided.
Excessive peak and/or trough serum concentrations of aminoglycosides may increase the risk of renal and eighth cranial nerve toxicity.
In the event of overdose or toxic reactions, hemodialysis may aid in the removal of this drug from the blood, especially if renal function is, or becomes compromised.
The rate of removal of this drug is considerably lower by peritoneal dialysis than it is by hemodialysis.
In the newborn infant, exchange transfusions may also be considered.

CONCOMITANT USE:

Concurrent and/or sequential systemic or topical use of other potentially neurotoxic and/or nephrotoxic drugs, such as cisplatin, cephaloridine, kanamycin, amikacin, neomycin, polymyxin B, colistin, paromomycin, streptomycin, tobramycin, vancomycin, and viomycin, should be avoided.
The concurrent use of this drug with potent diuretics, such as ethacrynic acid or furosemide, should be avoided, since certain diuretics by themselves may cause ototoxicity.
In addition, when administered IV, diuretics may enhance aminoglycoside toxicity by altering the antibiotic concentration in serum and tissue.

PREGNANCY:

Aminoglycosides can cause fetal harm when administered to a pregnant woman.

NARROW THERAPEUTIC INDEX:

This drug should be considered a narrow therapeutic index (NTI) drug as small differences in dose or blood concentrations may lead to serious therapeutic failures or adverse drug reactions.

Recommendations:

Generic substitution should be done cautiously, if at all, as current bioequivalence standards are generally insufficient for NTI drugs.
Additional and/or more frequent monitoring should be done to ensure receipt of an effective dose while avoiding unnecessary toxicities.

CONTRAINDICATIONS:

Hypersensitivity to the active component, other aminoglycosides, or any of the ingredients
Patients with a history of toxic reactions to this drug or other aminoglycosides

Consult WARNINGS section for additional precautions.

Dialysis

Hemodialysis:

Adults: 1 to 1.7 mg/kg IM or IV at the end of each dialysis period
Children: 2 to 2.5 mg/kg IM or IV at the end of each dialysis period

Peritoneal dialysis: Data not available

Comment: The dose depends on the severity of the infection.

Other Comments

Administration advice:

Implantable bead formulations:
Providers should take into account the direction in which the chain will be pulled out.
Health care providers should consider that the less the chains are fixed to connective tissue, the less painful it is for the patient and the easier it is to remove them.
The concentration of IV formulations should not exceed 1 mg/mL; this drug should be infused over a period of 30 minutes to 2 hours.
IM administration is preferred except when the route of administration is not feasible (e.g., patients in shock, with severe burns).
If an adverse reaction occurs, the infusion should be discontinued, appropriate countermeasures should be instituted, and the remainder of the fluid should be saved for examination if deemed necessary.

Storage requirements:

Bone cement: Store below 25C.
Implantable bead formulations: Store below 25C; do not freeze. Once the aluminum pouch has been opened, remaining beads must be discarded.

Reconstitution/preparation techniques:

Bone cement: The manufacturer product information should be consulted.
Injection solutions must be diluted prior to IV administration.

IV compatibility:

Compatible: Normal saline or 5% glucose in water
This drug should not be physically mixed with other drugs.

General:

IV administration may be useful in treating patients with severe burns, congestive heart failure, bacterial septicemia, shock, hematologic disorders, and/or those with decreased muscle mass.

Monitoring:

Cardiovascular: Blood pressure and pulse, especially during and directly after administration of a dose
General: Peak and trough levels
Nervous system: Vestibular function monitoring, especially during longer courses of treatment
Other: Auditory function monitoring, especially during longer courses of treatment
Renal: Regular renal function monitoring
Respiratory: Respiratory rate, especially during and directly after administration of a dose

Patient advice:

Patients should be told to report any unusual or severe side effects, including signs/symptoms of ototoxicity and nephrotoxicity.
Patients should be directed to take the full course of treatment, even if they feel better.
Advise patients to speak to their healthcare provider if they become pregnant, intend to become pregnant, or are breastfeeding.

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