Presentation on theme: "Training for junior doctors and pharmacists"— Presentation transcript:
1Training for junior doctors and pharmacists GentamicinTraining for junior doctors and pharmacists
2About this presentation This e-Learning package is in two parts.The first part will give you some background on gentamicin and the dosing regimens used to ensure safe and effective therapy.The second part looks at the version of the Hartford extended-interval regimen adopted by many trusts across Yorkshire.
3Learning Objectives After viewing this presentation, you should Understand the mechanism of action, indications and contra-indications of gentamicinUnderstand basic pharmacokinetics, as they apply to GentamicinBe able to apply the above to use the Yorkshire Hartford Gentamicin regimen.Understand the principles of pharmacokinetic and synergistic gentamicin regimens.
4PharmacologyGentamicin is a member of the aminoglycoside family of antibiotics. Aminoglycosides are bactericidal antibiotics active against many aerobic gram-negative bacteria and some aerobic gram-positive bacteria.Aminoglycosides act by disrupting protein synthesis at the bacterial ribosome.First aminoglycoside (streptomycin) discovered in Produced by species of Streptomyces and Micromonospora. Those derived from the latter e.g. gentamicin have an ‘i’ in the ‘mycin’ suffix.Composed of linked ring of amino sugars and aminoosubstituted cyclic polyalcohol (aminocyclitol). This moiety usually consists of 1 of 2 streptamine derivatives; streptidine or deoxystreptidine. The latter may be subdivided into the neomycin and kanamycin groups. The latter includes gentamicin, tobramycin and netilmicin.Gentamicin is active against staphylococci, and gram-negative bacilli including pseudomonas spp.Aminoglycosides penetrate poorly into mammalian cells, so of limited value in infections caused by intracellular bacteria.
5PharmacologyAminoglycosides are believed to act by binding to the 30S ribosomal sub-unit causingMisreading of the mRNA codon, leading to errors in amino-acid sequencingDisruption of polysomes, reducing the efficiency of protein synthesisInhibition of the translocation of tRNA between A and P ribosomal binding sitesCause misreading of mRNA codons, producing defective proteins which may affect cell membrane integrity, may cause formation of non-functioning initiation complexes, or inhibition of translocation during formation of polypeptides.None of these theories fully explains potent bactericidal activity of aminoglycosides compared with other protein synthesis inhibitors.Enter bacteria by active transport involving respiratory quinones. These are absent in streptococci, explaining their resistance, but action against them may be improved by synergy with penicillins.
6Side-effects of Gentamicin Damage to the cochlear and vestibular apparatus loss of balance, tinnitus, loss of hearing. May cause renal damage - risk of nephrotoxicity is increased with prolonged treatment. Concurrent use of other nephrotoxic drugs may exacerbate renal damage. Use with ototoxic diuretics, e.g. furosemide, may increase risk of ototoxicity and nephrotoxicity.May cause allergic reactions, nausea, vomiting and rashes.
7Cautions and Contra-indications Gentamicin is contra-indicated in severe renal impairment and pregnancy.It is contra-indicated in myasthenia gravis (due to its effects on nerve cells).It may increase the activity of neuromuscular blocking agents (although rarely clinically significant).May cause neuromuscular blockade and respiratory paralysis with curare-type muscle relaxants.
8So why use Gentamicin?Because it is very effective when used correctly.If levels are monitored appropriately, severe renal impairment and ototoxicity rarely occur.Low incidence of provoking Clostridium difficile infectionsIndicated in urinary-tract infections, chest infections, bacteraemia, septicaemia, and other systemic infections due to sensitive organisms.Usually active against most strains of : Escherichia coli, Klebsiella spp., Proteus spp. (indole positive and indole negative), Pseudomonas aeruginosa, Staphylococci, Enterobacter spp., Citrobacter spp and Providencia spp.Local guidelines recommend use in:Acute, hospital acquired UTIs;Pyelonephritis;Acute prostatitis;Severe diabetic foot;Listeria meningitis (with amoxicillin);Peritonitis (with Vanc and Met);Pelvic inflammatory disease;Pueperal sepsis or TOP;Infective endocarditis (with fluclox or benpen);Septicaemia (with Taz, vanc or dapto);Neutropenic sepsis;Surgical, orthopaedic and head and neck prophylaxis.
9Pharmacokinetics Study of how drugs pass through the body: Includes; absorption, distribution, metabolism and excretion.
10AbsorptionGentamicin is not readily absorbed from GI tract, so is given via intravenous route (may also be given IM).
11DistributionGentamicin is highly hydrophilic, i.e. not distributed into body fat and minimally distributed into tissue fluids.When calculating an appropriate dose, consider using the patient's lean mass (mass without excess fat = ideal body weight).Usually calculate dose using lower of actual or ideal body weight.
12EliminationGentamicin is excreted unmodified, by the kidneys and so follows "first order kinetics". i.e. drug is cleared from blood at a rate proportional to it's concentration.After a dose, level in the blood decays exponentially.
13EliminationGentamicin is excreted unmodified, by the kidneys and so follows "first order kinetics". i.e. drug is cleared from blood at a rate proportional to it's concentration.After a bolus dose, level in the blood decays exponentially.Kidneys continuously removing a constant fraction of gentamicin in the blood. As level goes down with time, less is excreted.If patient’s renal function compromised, excretion less efficient, so must be considered before commencing a course.
14Dosing Regimens Two types of regimens commonly used in UK: PharmacokineticExtended Interval.A 1996 paper (1) looked at meta-analyses comparing these regimens and found:Both regimens had equivalent efficacy, but;Extended Interval gentamicin had reduced nephrotoxicity.1Mega-analysis of meta-analysis: an examination of meta-analysis with an emphasis on once-daily aminoglycoside comparative trials. Pharmacotherapy Nov-Dec;16(6):
15Extended Interval Dosing May also be known as:Once daily dosing/administrationHartford dosingPioneered at Hartford hospital (Connecticut, USA) incorporating pharmacodynamic concepts of post-antibiotic effect and concentration-dependent kill.Regimen maximises bacterial kill whilst minimising toxicity.Post antibiotic effect is the apparent continuation of bacterial kill after the drug is cleared.Gentamicin is a concentration-dependant killer.
16Hartford Regimen – key points Hartford regimen is based on a consistent dose of 7mg/kg gentamicin calculated from the lower of the ideal body weight or actual body weight.Serum level is measured 6-14 hours after first dose to determine dosage interval.Nomogram is used to determine whether patient should receive gentamicin every 24 hours, 36 hours or 48 hours.
17Unless specifically recommended by microbiology Patient suitabilityDo NOT use Hartford regimen forPregnant womenChildren < 16 yearsUrology surgery prophylaxisAny patient who hasAscitesCystic fibrosisEndocarditis (unless requested by microbiology consultant)Major burnsRenal transplantRenal impairment – creatinine clearance <30mL/minUnless specifically recommended by microbiology
18Calculating creatinine clearance Don’t used automated eGFRUse a Cockcroft-Gault estimate:Men: (140 – age) x Weight (kg) x 1.23Serum creatinine (micromol/L)Women: (140 – age) x Weight x Serum creatinine
19Dose calculations Ideal body weight calculations: Female IBW = 45kg + (2.3kg x no. of inches over 5 feet)Male IBW = 50kg + (2.3kg x no. of inches over 5 feet)If patient is < 5 feet tall, use IBW = 45kg (females) or 50kg (males)
20AdministrationDilute gentamicin dose in mL sodium chloride 0.9% and give by intravenous infusion over 1 hour.Record exact start time of the infusion on drug chart.
21Measurement of levelsLook at your local policy for when your lab can receive gentamicin assaysDo not take blood sample from the IV line used for gentamicin administration!Take one blood sample (ideally 10mL) between 6 and 14 hours after the start of first infusion in a plain tube (clotted blood).Document on microbiology request form EXACT time and date infusion was set up and EXACT time and date sample was taken in addition to patient details and “Hartford Gentamicin Regimen.”
22Selecting dose interval If level falls in area designated 24 hours, 36 hours or 48 hours, dosing interval is 24, 36 or 48 hourly respectively.If level falls on a line between dosing intervals, choose longer interval.If level is above 48 hour line then STOP the treatment. If gentamicin is to be continued, take daily levels, but do not give any more gentamicin until level falls below 2mg/L
23Repeat monitoringCheck U & Es and creatinine daily to monitor renal function.If serum creatinine is rising significantly (≥20%) and time is within 6-14 hours of infusion, measure level ASAP, otherwise contact Microbiologist for advice.
24An example of how to complete the Yorkshire Hartford Gentamicin Regimen drug chart
30Complete the allergy/adverse drug effects box Rose Tyler3Smith12345660kg5'6"11/4/5058kgComplete the allergy/adverse drug effects box
31Rose Tyler3Smith12345660kg5'6"11/4/5058kgNKDAADr1/5/09Check the patient is not excluded. Calculate the Cockroft and Gault estimate of creatinine clearance to ensure that the patient has sufficient renal function to receive this regimen.(For this patient, they have a serum of creatinine of 90micromol/L and a creatinine clearance of 56ml/min)
32Rose Tyler3Smith12345660kg5'6"11/4/5058kgNKDAADr1/5/09Use the lower of the Actual Weight or Ideal Body Weight to calculate the 7mg/kg dose, rounded to the nearest 40mg. Alternatively, use the table on the reverse of the chart to determine the dose.
33Rose Tyler3Smith12345660kg5'6"11/4/5058kgNKDAADr1/5/09400mgThe first dose is administered to the patient. It is important that the time the infusion starts is recorded. The first blood test is due 6-14 hours after this time.
34The time the sample is actually taken must be recorded. Rose Tyler3Smith12345660kg5'6"11/4/5058kgNKDAADr1/5/09400mg9amKF AS15.00-23.00The time the sample is actually taken must be recorded.
35Rose Tyler 3 Smith 123456 9876641230 60kg 5'6" 11/4/50 58kg NKDA ADr 1/5/09400mg9amKF AS15.00-23.0019.0010When the gentamicin result is available, record this along with today's serum creatinine. Serum creatinine must be measured daily.
36This chart also shows when the next level is due. 1/5/09Smith60kgRose Tyler31234565'6"11/4/5058kgNKDAADr400mg9amKF AS15.00-23.0019.00105.585Refer to microbiology or pharmacy if serum creatinine is rising sharplyPlot the gentamicin level against the hours-post-dose on the chart on the back.This chart also shows when the next level is due.
381/5/09 Smith 60kg Rose Tyler 3 123456 9876641230 5'6" 11/4/50 58kg NKDAADr400mg9amKF AS15.00-23.0019.00105.585The process continues until gentamicin is no longer required. Remember to review the need for IV antibiotics on a daily basis.2/5/094/5/0921:0009:00400mgADr
39Pharmacokinetic Dosing Also known as:Traditional dosingMultiple-dose-per-day dosingTailored dosingConventional dosingUse for patients excluded from Hartford.Bolus doses calculated according to estimated measures of distribution and excretion of gentamicin.Most preparations only licensed for multiple-dose per day administration.
40Pharmacokinetic dosing Discuss with microbiology or pharmacy appropriate dosesMeasure levels after 3 – 5 doses.Need to monitor both peak (post-dose) and trough (pre-dose) levels.Take pre-dose sample immediately (1 hour) before next dose, post-dose 1 hour after dose is finished.
41Synergistic DosingForm of pharmacokinetic dosing, used in treatment of endocarditis, and other streptococcal or enterococcal infections.Usually gentamicin plus cell wall inhibitor (e.g. benzylpenicillin, flucloxacillin or vancomycin).Combination synergistic, so lower serum concentrations of gentamicin needed - typically peak of 3-5mg/L and trough of less than 1mg/L.Synergy only occurs when both gentamicin and cell wall inhibitor given together – hence multiple doses per day.
42Synergistic DosingEndocarditis usually requires a minimum of 2 weeks aminoglycoside therapy, so lower serum concentrations minimise nephrotoxicity and ototoxicity.In young patients without renal impairment, start synergistic dosing with a dose of 1mg/kg 8 hourly.For elderly patients / patients with poor renal function contact Pharmacist or Microbiologist for advice.
43Hartford Extended Interval dosing Pharmacokinetic Dosing SummaryHartford Extended Interval dosingPharmacokinetic DosingInitial Dose7mg/kg, with dose frequency altering according to nomogram based upon gentamicin serum concentrationAdults: 2mg/kg loading dose, then refer to pharmacy or microbiology for maintenance doseSynergistic dosing for endocarditis1mg/kg TDS (or less frequently)Paediatrics: 2.5mg/kg TDSAdjust dose and frequency based upon gentamicin serum concentrationAdministrationInfusion in ml Sodium Chloride 0.9% over 30 minutesBolus over at least 3 minutesBlood levelstakenOne sample taken 6-14 hours after the infusion commences Just before the dose (pre-dose sample) and 1 hour (post-dose sample)TargetconcentrationsNo target - use the nomogram to identify the patient's required dosing interval.Standard:Pre-dose <2mg/L, Post-dose 6-10mg/L Synergistic dosing for endocarditis: Pre-dose <1mg/L, Post-dose 3-5mg/L
44CreditsYorkshire Hartford Gentamicin developed with the assistance of the Yorkshire and Humber Antimicrobial Pharmacist networkIn particular: Pam Garnett, Peter Taylor, Alison Haigh, Andy Karvot and Philip HowardRegimen developed fromNicolau et al Experience with a Once-Daily Aminoglycoside Program Administered to 2,184 Adult Patients. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, 1995; 39(3): 650–655This Yorkshire Hartford regimen protocol and associated materials can be used, without guarantee or warranty by other healthcare professionals providing it is on a not-for-profit basis and any resulting materials are shared on a similar basis