Cqod 04/21

[PharmDstudent]

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Loading dose of Amikacin in hemodialysis patient with CrCl of 17?

 

[Sparda29]

Whats the weight? 10 mg/kg for load dose though.

 

[PharmDstudent]

58kg

 

[Its Z]

What are you treating

 

[PharmDstudent]

What are you treating

Not sure exactly. Fevers, fevers, fevers - "life-threatening"

 

[rxlea]

Yeah why not another AG. What's the bug

 

[KARM12]

Why are you calculating CrCl on an HD patient?

 

[PharmDstudent]

Yeah why not another AG. What's the bug

This is the second AG, but still feverish. I wish I had 3 days to figure that out, but the empirical clock is ticking. 😉

Why are you calculating CrCl on an HD patient?

Do you determine trough or just dialyze? The most cautious was is to get a CrCl and trough separately from HD. Patient's getting pretty weak. 😱

 

[Its Z]

Amikacin is a good drug.
Not worried about renal toxicity.
I would go with 7.5mg/kg for a peak of 30. After dialysis just replace the dialyzes amount. If worried about ototoxicity....maybe 1/2 the dose

 

[Its Z]

Crcl is irrelevant. Trough is not important. Ag. Is concentration dependant bactericidal.

 

[PharmDstudent]

Amikacin is a good drug.
Not worried about renal toxicity.
I would go with 7.5mg/kg for a peak of 30. After dialysis just replace the dialyzes amount. If worried about ototoxicity....maybe 1/2 the dose

That's what we came up with too...

"First, initiate therapy by administering a normal dose, 7.5 mg/kg, as a loading dose. This loading dose is the same as the normally recommended dose which would be calculated for a patient with a normal renal function as described above." - www.globalrph.com/amikacin_renal.htm

Crcl is irrelevant. Trough is not important. Ag. Is concentration dependant bactericidal.

Trough above 10 is supposedly toxic.

"...above 10 micrograms per mL should be avoided"

 

[njac]

Loading dose of Amikacin in hemodialysis patient with CrCl of 17?

Do you even factor in "CrCl" if patient is on HD?

 

[njac]

That's what we came up with too...

"First, initiate therapy by administering a normal dose, 7.5 mg/kg, as a loading dose. This loading dose is the same as the normally recommended dose which would be calculated for a patient with a normal renal function as described above." - www.globalrph.com/amikacin_renal.htm

Trough above 10 is supposedly toxic.

"...above 10 micrograms per mL should be avoided"

What are you going to do, kill their kidneys?

(then the question comes to are they ESRD or AKI)

 

[njac]

Is amikacin still on shortage? I know it was a problem last year.

Is it being started empirically or do you have old cultures?

 

[Praziquantel86]

What is the patient's PMH? Microbiology history? Current chief complaint? Bueller?

Amikacin is being distributed on a need-based basis...does this patient qualify? Things we need to know.

 

[psychoandy]

2nd AG? Resistance? Amikacin is still in short supply at my institution.

 

[cycloketocaine]

Man, we have bookoos of Amikacin. I think our buyer went a little nuts when she had the chance.

 

[PharmDstudent]

Do you even factor in "CrCl" if patient is on HD?

No, but in this case, dialysis may or may not be an option.

What are you going to do, kill their kidneys?

(then the question comes to are they ESRD or AKI)

ESRD. What am I going to do, walk them down to dialysis myself?

If they make it out alive, I would like them to be able to hear. The lab for this is offsite, so that makes it even more worrisome.

Is amikacin still on shortage? I know it was a problem last year.

Is it being started empirically or do you have old cultures?

Supply problem?... No, not at this moment.

Empirically. Previous cultures are still pending.

What is the patient's PMH? Microbiology history? Current chief complaint?

Multiple comorbidities, LTC patient. Hmmm... I don't think microbial history is important at this point. Current chief complaint: why haven't I gone to hospice already?

Bueller?

... in the mean time... during her time off, PharmDstudent is thinking...

...

Amikacin is being distributed on a need-based basis...does this patient qualify? Things we need to know.

I would hope so. It's an LTAC facility, afterall.

2nd AG? Resistance? Amikacin is still in short supply at my institution.

The labs are still pending.

 

[njac]

I was asking about antimicrobial hx because I've never worked anywhere that amikacin was the workhorse aminoglycoside.

I've seen far more Tobra.

 

[PharmDstudent]

I was asking about antimicrobial hx because I've never worked anywhere that amikacin was the workhorse aminoglycoside.

I've seen far more Tobra.

Oh, I see. I'll find out.

 

[rxlea]

I was asking about antimicrobial hx because I've never worked anywhere that amikacin was the workhorse aminoglycoside.

I've seen far more Tobra.

This

 

[habeansha]

really OT but, i was studying for my NAPLEX and had a question

Using nebulized TOBI for CF, do you need to get drug levels?

 

[cycloketocaine]

really OT but, i was studying for my NAPLEX and had a question

Using nebulized TOBI for CF, do you need to get drug levels?

Probably not, it generally isn't systemically absorbed. Sometimes we get just a trough to make sure that the drug doesn't get systemically absorbed, there are case reports of that happening.

ETA: Generally we only check for accumulation in kids with crappy kidneys or if kidney function tanks.

 

[xiphoid2010]

I was asking about antimicrobial hx because I've never worked anywhere that amikacin was the workhorse aminoglycoside.

I've seen far more Tobra.

At my place, our kleb, proteus and e. coli are all 20-25% resistant to gent and Tobra, only amikacin is still <10%. Yeah, docs here used to be very liberal with abx.

 

[Praziquantel86]

Empirically. Previous cultures are still pending.

Multiple comorbidities, LTC patient. Hmmm... I don't think microbial history is important at this point. Current chief complaint: why haven't I gone to hospice already?

The labs are still pending.

Previous micro history is very important, if available. I generally would not use amikacin empirically unless the patient had a prior history of resistance/allergies to alternative agents. Based on my institution's microbiology, the only thing we can reliably use amikacin for is Pseud - Enterobacteriaciae resistant to other AGs are commonly resistant to amikacin as well around here (target site modification vs. molecular modification). Not to mention the fact that, hey, maybe (likely) she's had VRE in the past.

We also run into the problem of using an aminoglycoside for a UTI in a patient who is HD, indicating that site concentrations are so minimal to the point that I'd worry about efficacy even if susceptible in vitro.

So, long story short, I'm looking for a reason to not use amikacin, due to the factors that I've mentioned here plus the fact that aminoglycosides are not the best agents to use in HD due to pharmacodynamic considerations. We can come up with a dose if necessary, but the question is, is it necessary?

 

[psychoandy]

What praz said. Unless you were suspecting pan-resistant pseudomonas or nocardia or something really weird i would never reach for amikacin even as a 2nd line...unless I was too cheap to have carbapenems on formulary.

Not trying to be snarky, i know this isn't a formal case presentation, but...we have no idea of past medical hx, surgical hx, infection/culture hx, other antibiotics currently on board, etc. Having multiple medical problems and probably needing hospice isn't a contraindication to abx. You said this is 2nd aminoglycoside, so what was the first? Are gent/tobra 1st line in your LTAC (weird...must be for profit and super cheap or something).

possible sources? indwelling cath? prior GI surgery? infected AV fistula? do you even have a chest xray? maybe it's drug fever due to abx polypharmacy? we're not in the field of diagnosis (thank god) but we do need to have some idea of what to treat.

 

[KARM12]

AG have their place...they work great. I love giving them to HD patients because I don't need to worry about losing their kidneys.

ID rookies...throwing out the meropenem, that is poor stewardship.

It is too hard to tell what the best option for the patient based on the information given. PharmDstudent was just asking for the dosing, not the choice of drug.

 

[psychoandy]

PharmDstudent was just asking for the dosing, not the choice of drug.

anyone can look up dosing on lexi or micromedex. generally when i verify/send orders i like to have some sort of idea of why they picked that drug. and i don't come from an area with high resistance to AGs, so this is somewhat bizzare to me. is this not a thread for clinical discussion?

 

[PharmDstudent]

AG have their place...they work great. I love giving them to HD patients because I don't need to worry about losing their kidneys.

ID rookies...throwing out the meropenem, that is poor stewardship.

It is too hard to tell what the best option for the patient based on the information given. PharmDstudent was just asking for the dosing, not the choice of drug.

Right. The ID specialist was in charge of drug choice, cultures, etc.

anyone can look up dosing on lexi or micromedex. generally when i verify/send orders i like to have some sort of idea of why they picked that drug. and i don't come from an area with high resistance to AGs, so this is somewhat bizzare to me. is this not a thread for clinical discussion?

Try finding the dose yourself. It wasn't straightforward and had to be determined using our "best judgement". It took us a while to find the right numbers to hang our hat on.

 

[PharmDstudent]

really OT but, i was studying for my NAPLEX and had a question

Using nebulized TOBI for CF, do you need to get drug levels?

No

 

[cycloketocaine]

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