Clinical Guideline

AMINOGLYCOSIDE GUIDELINE FOR CHILDREN

SETTING Bristol Royal Hospital for Children (BRHC)

FOR STAFF Staff involved in the prescribing, checking and administration of

aminoglycosides

PATIENTS Paediatric inpatients (under 18 years) at Bristol Royal Hospital for Children.
This guideline does not apply to:
• Paediatric inpatients in the neonatal unit at St Michael’s Hospital
• Adult (18 years or above) inpatients at Bristol Royal Hospital for
Children
• Paediatric inpatients who are receiving gentamicin for endocarditis

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GUIDANCE
Aminoglycoside antibiotics carry a risk of nephrotoxicity, irreversible ototoxicity and vestibular
toxicity. Communication of these risks with patients and their families and monitoring of
aminoglycoside trough levels and renal function are therefore paramount during therapy.

• The risk of nephrotoxicity and ototoxicity must be communicated to all children (who are
able to understand such risks) and their families/carers by the doctor prior to commencing
aminoglycoside therapy. This should be documented in the medical notes.
• Monitoring of serum trough aminoglycoside levels is mandatory throughout therapy to
minimise toxic drug levels in the blood. See schedule below.
• Renal function must be checked at the start of IV therapy and at least twice weekly
throughout therapy.
• Ensure adequate hydration throughout the duration of the course.
• Audiology assessments should be considered:

o For patients who have extended courses of aminoglycosides

o For patients who have repeated courses of aminoglycosides
o Where there are concerns about a child’s hearing
o If trough drug levels have been in the toxic range during a treatment course

Prescribing aminoglycosides (gentamicin, tobramycin, amikacin)

• Gentamicin is the aminoglycoside of choice at the Trust unless otherwise stated in
specific guidelines or by microbiology.
• Aminoglycosides should only be used for a maximum of 7 days unless discussed with
microbiology, or in patients with cystic fibrosis (CF).
• Prescribe all aminoglycosides on the paediatric aminoglycoside chart.
• Check renal function at the beginning of treatment and at least twice a week for all
children with normal renal function on prolonged aminoglycoside treatment. More
frequent monitoring of renal function should be carried out if renal impairment is present.

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Obese patients
There is no national definition of obesity in children but both NICE and SIGN have issued
guidance3,4. BMI cannot be used in isolation, but should be expressed as a BMI centile in relation
to an age- and sex-matched population.

BMI = weight (kg)/height 2 (m2)

The general consensus is:

• If BMI >91st centile patient defined as overweight

• If BMI >98th centile patient defined as obese

Obese dose calculation:

• Calculate Ideal Body Weight (IBW) from the child height-weight growth charts using the
proportional weight for the child’s height

• Use this to calculate the Dose Determining Weight (DDW)

• DDW (kg) = IBW + 0.4 x (actual body weight (kg) - IBW)

• Use DDW to determine the once daily aminoglycoside dose

In summary: if the child is determined to be obese (as per the definition above), calculate Ideal
Body Weight (IBW) and subsequently Dose Determining Weight (DDW). If there are no concerns
use Actual Body Weight (ABW) to calculate the dose.

Renal Function
• Formula to calculate renal function: eGFR (ml/min/1.73m²) Schwartz Formula:

a. Formula for children <1 yr old: (30 x height in cm)/(serum creatinine in µmol/L)
b. Formula for children >1 yr old: (36.5 x height in cm)/(serum creatinine in µmol/L)

• For patients on renal replacement therapy, please consult on call paediatric nephrologist.

If concerned about previous high levels and renal insufficiency discuss with the consultant and:

• For tobramycin and amikacin consider a 20%1 dose reduction.

• For gentamicin consider increasing dosing interval.

Trough levels should never be taken from the same line that the antibiotic was given through
(this includes port-a-caths and long lines). It is therefore most appropriate to take a peripheral
venous sample or finger-prick sample.

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Table 1:

GENTAMICIN – age >28 days*

Where to Creatinine Urine output Dose Target Level First Give Give Result of Next
prescribe trough level dose 2 dose 3 first level**
level without without level**
result of result of
level? level?

Normal Aminoglycoside Normal range >1ml/kg/hr 7mg/kg* <1mg/L Tick level 1 Yes No Target Take
renal chart for age >28 & give hour level in further
function OD days of (green pre range, give levels
And life* box) on the 2nd dose 3 twice a
(Max dose:
drug chart dose week
Age >28 days* 520mg/day)

Borderline Aminoglycoside Greater than 0.5-1ml/kg/hr 5mg/kg <1mg/L Tick level 24 No No Target Every 48
renal chart normal values >28 & hold (red hours level in hours
function for age OD initially days of box) on the after range, give
and then as life* drug chart first dose 2
per trough dose
levels

Impaired Front of drug Known <0.5ml/kg/hr 2.5mg/kg <1mg/L Prescribe 24 NA NA Target 24 hours
renal chart chronic/acute >28 one dose hours level in after
function renal failure days of on the after range, dose
life* STAT side first prescribe
of the drug dose next dose
chart on front of
drug chart

* See table 5 for neonatal dosing

**If abnormal results refer to table 4

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Table 2:
TOBRAMYCIN

Where to Creatinine Urine output Dose Target Level First Give dose Give Result of Next
prescribe trough level 2 without dose 3 first level**
level result of without level**
level? result of
level?

Normal Aminoglycoside Normal range >1ml/kg/hr Non-CF: <1mg/l Tick level 1 hour Yes No Target Non-CF:
renal chart for age 7mg/kg & give pre level in Take
function OD (green 2nd range, further
And box) on dose give dose levels
CF: the drug 3 twice a
Age>28 days* 10mg/kg chart week
OD
CF: on
(max for day 9 of
both non- therapy
CF and
CF
640mg)

Abnormal Aminoglycoside Greater than <0.5ml/kg/hr Non-CF: <1mg/l Tick level 1 hour No No Target Non-CF:
renal chart normal values 7mg/kg & hold pre level in Take
function or for age OD (red box) 2nd range, further
history of on the dose give dose levels
high levels CF: drug 2 twice a
10mg/kg chart week
OD
CF: on
(max for day 9 of
both non- therapy
CF and
CF
640mg)

**If abnormal results refer to table 4

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Table 3:
AMIKACIN

Where to Creatinine Urine Dose* Target Level First Give Give Result Next level**
prescribe output trough level level dose 2 dose 3 of first
without without level**
result result
of of
level? level?

Normal Aminoglycoside Normal >1ml/kg/hr Non-CF: <3mg/l Tick 1 hour Yes No Target Non-CF: Take
renal chart range for 15mg/kg level & pre 2nd level in further levels
function age OD give on dose range, twice a week
the give
CF: drug dose 3 CF: on day 9 of
30mg/kg chart therapy
(max:1.5g)
OD

Abnormal Aminoglycoside Greater <0.5ml/kg/hr Non-CF: <3mg/l Tick 1 hour No No Target Non-CF: Take
renal chart than 15mg/kg level & pre 2nd level in further levels
function normal OD hold on dose range, twice a week
or history values for the give
of high age CF: drug dose 2 CF: on day 9 of
levels 30mg/kg chart therapy
(max:1.5g)
OD

*Maximum total cumulative dose per course = 15g (non-CF patients)

**If abnormal results refer to table 4

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Table 4:
Abnormal results (higher trough than recommended ranges)

First Level Second Next level Normal High result

dose given Result

Normal renal 1 hour pre 2nd Yes 24 hours Continue 24 Repeat level
function dose after dose 2 hourly in 12 hours

Abnormal renal 1 hour pre 2nd No 12 hours Switch to 36 Repeat level

function dose after first hourly in 12 hours
level

• If trough levels are within the normal range, therapy may continue at the current dose and frequency.
• Trough levels must also be repeated following any change in dose or drug interval, or if there is a deterioration in renal function.
• More frequent monitoring may also be required if other nephrotoxic drugs are prescribed.
• If trough levels exceed these thresholds with normal renal function:
o Gentamicin: adjust dosing intervals
o Tobramycin and Amikacin: when level is satisfactory, recommence once-daily therapy, reducing the dose by 20%1.
o Re-check the trough level prior to the next dose, withholding that dose until the level is known.

• Renal function must be checked at the start of IV therapy and at twice weekly intervals throughout therapy.
• If renal function continues to deteriorate discuss antibiotic choice with microbiology and dosing with the renal team.
• Gentamicin levels are assayed in the BRI biochemistry laboratory.
• Tobramycin and amikacin levels are processed by Southmead and will be reported on the same day if received in the laboratory before
3pm.

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Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist
Table 5:

Neonatal Dosing

Gentamicin dose Trough level

Neonate 0-7 days and >32 <2mg/L

5mg/kg every 36 hours
weeks gestational age (<1mg/L if more than 3 doses administered)

< 2mg/L
Neonates 8- 28 days 5mg/kg every 24 hours
(<1mg/L if more than 3 doses administered)

References:
1. Royal Brompton & Harefield NHS Foundation Trust. Clinical Guidelines: Care of Children with Cystic Fibrosis, Royal Brompton Hospital. 2104; 6th ed.
2. BNFC, accessed on-line:June 2017
3. Management of obesity. A National Clinical Guideline. SIGN, February 2010. Accessed on-line, June 2017.
4. Managing overweight and obesity among children and young people: lifestyle weight management services. NICE Public Health Guidance 47, October 2013.
Accessed on-line, June 2017.
5. Traynor et al., 1995 Aminoglycoside dosing weight correction factors for patients of various body sizes. Antimicrobial Agents and Chemotherapy. 39:545-548
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RELATED Trustwide antibiotic prescribing guidelines

DOCUMENTS http://connect/ClinicalCare/ClinicalPracticeGuidance/TrustwideClinicalPracticeGuidance/Antibiotics/Pages/default.aspx

AUTHORISING BODY Anti-infectives Steering Group

Children’s Effectiveness Committee

SAFETY N/A

QUERIES Monday to Friday 9am to 5pm contact the ward pharmacist (or microbiology queries on ext 29269)
Out of hours contact Microbiology via switchboard.

Version 2 From: Apr 20 – To: Oct 22 Author(s) Rogers R, Gage S, Batten W, Crampton R, Paediatric Pharmacists, Page 7 of 7
Vergnano S, Paeds ID, Wade S, Anti-infective pharmacist