Quick Reference

http://www.rch.org.au/clinicalguide/cpg.cfm?list=all

Lepirudin (Refludan)

• Direct Thrombin Inhibitor (Anticoagulant)
• Use in HIT, DVT, PE
  
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Aminoglycoside Calculation (Synergy)

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GRAM-POSITIVE COMBINATION DOSING (“SYNERGY”)

-Patients with serious Gram-positive infections may receive aminoglycosides in combination to achieve synergistic killing.

Inclusion criteria:

Patients with serious Gram-positive infection (e.g. endocarditis) being treated with a b-lactam or vancomycin.

Exclusion criteria

Patients with documented serious Gram-negative infections (e.g. Pseudomonas) receiving aminoglycosides in combination with a b-lactam agent. (see above)

Dosing:

CrCl	Dose (gentamicin)
>60 ml/min	1 mg/kg/dose IV q8h

·Contact pharmacy for maintenance doses for patients with CrCl <60>

Monitoring:

·Patients with who are anticipated to receive aminoglycosides for ≥7 days should have levels monitored.

·For patients who require monitoring, draw peak and trough level.

·Peak levels should be drawn 30 minutes after the end of the infusion. Trough levels should be drawn immediately before the next dose. Levels should be drawn around the 3^rd or 4^th dose to allow the drug to reach steady-state.

	Desired level (gentamicin)
Trough	≤1 mg/ml
Peak	3 mcg/ml

Ref : UCSF Infectious Disease Management Program.

Aminoglycoside Calculation

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MULTIPLE-DAILY DOSING (“TRADITIONAL”)

-This approach should be used for the treatment of Gram-negative infections when “once-daily” dosing is not appropriate.

Inclusion criteria:

Patients with suspected or documented Gram-negative infections not eligible for “once-daily” dosing.

Patients with documented serious Gram-negative infections (e.g. Pseudomonas) receiving aminoglycosides in combination with a b-lactam agent.

Exclusion criteria:

Patients using aminoglycosides for synergistic activity against Gram-positive organisms (see below).

Dosing:

CrCl	Dose (gentamicin, tobramycin)
>60 ml/min	1.5-1.7 mg/kg/dose IV q8h
40-60 ml/min	1.2 - 1.5 mg/kg/dose IV q12h
20-40 ml/min	1.2-1.5 mg/kg/dose IV q12-24h
<20>	2 mg/kg loading dose

·A 2mg/kg loading dose may be administered in patients with severe infections.

Monitoring:

·Patients with who are anticipated to receive aminoglycosides for ≥7 days should have levels monitored.

·For patients who require monitoring, draw peak and trough level.

·Peak levels should be drawn 30 minutes after the end of the infusion. Trough levels should be drawn immediately before the next dose. Levels should be drawn around the 3^rd or 4^th dose to allow the drug to reach steady-state.

	Desired level (gentamicin, tobramycin)
Trough	<2>
Peak	5-8 mcg/ml