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Therapeutic drug monitoring has been the standard of care when administering aminoglycosides for many years. Aminoglycoside levels are variable among individuals, and subtle changes in the volume distribution, renal blood flow, and filtration rate can affect renal handling of aminoglycosides and alter the risk of nephrotoxicity. For these reasons, therapeutic drug monitoring, in combination with or independent from, single-dose daily treatment regimens is recommended.318–321 When using therapeutic drug monitoring in single-dose or extended-dose treatment strategies, the Cmax should be at least 10-fold greater than the MIC of the infecting microorganism. This Cmin (trough level) should be undetectable by 18–24 hours to limit accumulation of aminoglycosides in renal tubular cells and to minimize the risk of AKI. The usual dosing strategy for once-daily aminoglycosides is 5 mg/kg/d for gentamicin and tobramycin (with normal renal function); 6 mg/kg/d for netilmicin; and 15 mg/kg/d for amikacin. The multiple-dose daily regimen for gentamicin and tobramycin is usually 1.7 mg/kg every 8 hours with peak blood levels at 8 ± 2 µg/ml (17 ± 4 µmol/l) and trough of 1–2 µg/ml (2–4 µmol/l). Amikacin levels with the multiple-dose daily dosing strategy should be a peak of 20 ± 5 µg/ml (34 ± 9 µmol/l) and a trough of 5–8 µg/ml (9–14 µmol/l). We recommend therapeutic drug monitoring when using prolonged courses of aminoglycosides to limit the risk of nephrotoxicity when using multiple-daily dosing, and suggest therapeutic drug monitoring when using singledaily dosing strategies.
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