Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

TOBRAMYCINUsual DoseAdult: 2.5 mg/kg Q12H IV/IM OR 5 mg/kg Q24H IV/IM OR 1.5 mg/kg Q8H IV OR 7 mg/kg Q24H IV [in VAP] (UWHCcost/day $3.75-5.84).Urinary tract infections 1-3 mg/kg daily IV/IM.TOBI nebulizer solution 300 mg Q12HPediatric:** 3-6 mg/kg/day in divided doses Q8H (cystic fibrosis 7-10 mg/kg/day).Note: Dose using IBW. For obese patients (BMI>30 kg/m 2 ) use a dosing weight(DW) = 0.4 (ABW-IBW) + IBW.(IBW=Ideal Body Weight; ABW=Actual Body Weight)Indications1. Pseudomonas aeruginosa infections (use with an anti-pseudomonal beta-lactam).2. Pseudomonas aeruginosa bronchitis, bronchiectasis or pneumonia in cystic fibrosis patients.3. Gram-negative organisms with documented or suspected gentamicin resistance where susceptibility to tobramycin isknown or considered likely.4. Serious urinary tract infections as monotherapy.5. Febrile neutropenia - in combination with a beta-lactam.CommentsTobramycin has superior activity to gentamicin against P aeruginosa, but is less active against other Gram-negativebacilli. Tobramycin may be marginally less nephrotoxic and ototoxic than gentamicin. In cystic fibrosis patients with normalrenal function, the initial dose for tobramycin is 10 mg/kg given once daily or divided into two to three doses. Further doseadjustments may be based upon serum levels. For extended-interval (Q24H) dosing draw midpoint level 8 - 12 H after thestart of infusion. For Q12H dosing draw peak and trough (peak: 30 minutes after the end of either a 30 minute or 60minute infusion; trough: 15-30 minutes prior to next dose). Note: The dose listed for urinary tract infections assumes thepatient does not have systemic inflammatory response syndrome. The unit pharmacist will assist in pharmacokineticdosing. With Q12 to 24 hour dosing blood level monitoring is needed only for patients with compromised renal function orpatients with rapid clearances, e.g., burn patients. Clearance into urine is poor with creatinine clearance < 15 mL/min.Aminoglycosides must be used with caution in patients with renal insufficiency, cirrhosis with ascites or patientswho have been on cisplatin within the last 21 days, all because of the increased risk of nephrotoxicity.If susceptibility testing indicates susceptibility to gentamicin, except for Pseudomonas infections, changing fromtobramycin to gentamicin may result in a significant cost savings.TRIMETHOPRIMUsual DoseAdult: PJP treatment 20 mg/kg/day PO (UWHC cost/day $2.96).Pediatric:** 4 mg/kg/day PO in divided doses Q12H.Indications1. Pneumocystis jiroveci pneumonia treatment in combination with dapsone (third-line therapy).TRIMETHOPRIM/SULFAMETHOXAZOLEUsual DoseAdult: 8-10 mg TMP/40-50 mg SMX /kg/day in 3-4 divided doses IV (UWHC cost/day $10.21-12.76) including skininfections with MRSA. For PJP 15-20 mg/kg/day of TMP component in 3-4 divided doses. Dose for prostatitis and UTImay be 160 mg/800 mg orally twice daily. (UWHC cost/day $0.11)For PJP prophylaxis, give one double-strength tablet 3 times/week - once daily. (UWHC cost/day $0.06)Pediatric:** 6-12 mg TMP/30-60 mg SMX/kg/day in divided doses IV Q6H, PO Q12HIndications1. Uncomplicated urinary tract infection, including acute prostatitis, caused by susceptible strains of E coli, P mirabilisand Klebsiella spp.