Checklist for prescribing aminoglycosides

Is there a clear indication for aminoglycoside therapy?

See the indications for aminoglycoside therapy in these guidelines or local protocols. Aminoglycosides are primarily indicated for short-term empirical therapy but may also be used for directed therapy.

Does the patient have contraindications or precautions that preclude aminoglycoside use?

There are few contraindications to aminoglycoside use. However, use aminoglycosides with caution in patients at increased risk of toxicity. Aminoglycoside precautions and contraindications for use are listed in Aminoglycoside contraindications and precautions.

Is the patient likely to have altered pharmacokinetics?

For patients with altered pharmacokinetics (see Patients with altered pharmacokinetics), modified dosages may be required and close monitoring is necessary.

Is the patient’s kidney function known?

The patient’s kidney function influences aminoglycoside dosage (eg initial dose in adults, frequency of dosing, whether repeated doses can be used). If the patient is critically ill, it is appropriate to administer an initial empirical dose without ascertaining kidney function.

How is the appropriate aminoglycoside dosage determined?

The choice of dosage should be made with consideration of the patient’s clinical status and comorbidities.

The appropriate aminoglycoside dosage is determined by the patient’s weight and kidney function – see Aminoglycoside dosing and administration. For dosages in adults with altered pharmacokinetics due to causes other than obesity, seek expert advice.

When gentamicin is used for synergy with cell-wall–active drugs (eg beta lactams, glycopeptides), multiple-daily dosing is generally required.

Is the aminoglycoside therapy empirical or directed?

Empirical aminoglycoside dosing should not continue beyond 48 hours. If empirical antibiotic therapy is still required at 72 hours, switch to an alternative antibiotic.

If directed therapy is expected to be prolonged (eg for enterococcal endocarditis), confirm aminoglycoside susceptibility.

Is plasma concentration monitoring required?

Monitoring aminoglycoside plasma concentrations is generally not required for therapy that will be stopped within 48 hours. However, consider monitoring from the first dose if kidney function is changing rapidly or substantially, or in patients with altered pharmacokinetics (eg patients with obesity).

Plasma concentration monitoring is mandatory from the first dose if therapy is expected to continue for more than 48 hours.

Undertake clinical monitoring for toxicity in all patients.

See Clinical monitoring for aminoglycoside toxicity.