TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN DO NOT WRITE in THIS BINDING MARGIN II Cm Page 2 of 5 F F

DO NOT WRITE IN THIS BINDING MARGIN

00007:658202 00007:658202_v4.00 -03/2020 need InfectiousDiseases(ID)inputandapprovaltoreceiveongoingtherapy prescribing. All patients(exceptCysticfibrosispatients)requiringmorethan48hoursof Tobramycin/Gentamicin, All patientsreceiving Tobramycin/ Gentamicinshouldhaveappropriatedruglevelsorderedatthetimeof intended tobeusedbymedical,nursingandpharmacystaff. assist withsafeprescribingof Tobramycin andGentamicininourpaediatricpatientpopulation. This worksheetis The purposeofthisworksheetistoprovidespecificdrugdosingandtherapeuticmonitoringinformation INSTRUCTIONS PURPOSE Your Clinical Pharmacistisavailablefor adviceonalldoseadjustments. has notchanged, aftereachdoseadjustment andafter7days. Recheck 2hour and6hourpostdoselevels (torecalculate AUC) aswell as renalfunctiontoensureclearance Perform AUC therapeuticdrugmonitoringafterDOSE ONEor TWO ifcourse istocontinuefor5ormoredays. Complicated infections(for examplefebrileneutropenia,sepsis/septicshock, bacteraemias): of theaminoglycoside,not therapeuticefficacy). or longer. Aim fortroughlevellessthan1mg/L. (Caution: Trough levelmonitoring onlyindicatesrenalclearance Perform apre-dose(truetrough) levelbeforedose TWO or THREE iftreatmentislikelytocontinue for72hours Uncomplicated infections(forexampleUrinarytract infections): repeated coursesofaminoglycosidesorwhomightbe atriskofototoxicity urine dipstickforproteinuriaisalsorequired.Consider audiologyinpatientswhoarelikelytoreceiveprolonged/ as renalfunctiontoensureclearancehasnotchanged, aftereachdoseadjustmentand7days.W consultation withrespiratoryteam.Recheck2hourand 6hourpostdoselevels(torecalculate - timedfromstartofinfusion),afterDOSEONEandthen asrecommendedbytheclinicalpharmacistin Perform AUC therapeutic drugmonitoring(apairofbloodsamplestaken2-3hoursand6-8postdose Cystic Fibrosis/NonCFBronchiectasis: If administrationduration/timevariationsoccur, pleasenotedetailsandreasononthisform. calculated area and medicalstafftoaccuratelyrecordtimesforadministrationbloodsampling.Smalldeviationscan alter the with drug.Infusingfasterorslowerwillchangethepeakserumtobramycinlevel(C restricted oraneonate–smallervolumemayberequired with SodiumChloride0.9%andgivenover30minutes Reconstitution andadministration:Itisrecommendedthattheaminoglycosidedosebemadeupto 30mL levels tobecollectedinbusinesshours(exceptionendocarditis;consultwithW Timing ofdose: • • • Commence Dosing: CysticFibrosispatients Septic/critically illchildren>10yearsold: Children >10yearsoldandadolescents: Infants over1monthofageandChildrenyoungerthan10yearsold: Term Neonatesweek1to4oflife: professionals/antimicrobial-stewardship/guidelines/neonatal-dosing recommendations ontheCHQ AMS website–link: Premature neonates(youngerthan35weekspostmenstrualage): In obesepatients,useidealbodyweightfordosecalculation. Commence doseofintravenous(IV) Tobramycin/Gentamicin at Dosing: FOR ALL OTHER INDICATIONS THERAPEUTIC DRUG MONITORING volume ofdistributionwithincreasingage)–seekspecialistadviceondosing. Caution: Adolescents morethan12yearsofage: mg/kg dose1adjustedforcurrentweight(iflessthan3monthshaselapsedbetweenadmissions) 1 monthto12yearsofage: Therapeutic DrugMonitoring Tobramycin/Gentamicin Non Teenage patientsdoserequirementscandecreasewithincreasingage(reducedrenalclearanceand IV Tobramycin -Cystic Fibrosispatients under thecurve Dosesareideallychartedfor at: 10mg/kgoncedaily(maximum640mginitialdose)ORpreviouslyoptimised (AUC)andthereforeaccuracyofdoserecommendations. 5mg/kg/day 6mg/kg/day(max560mginitialdose) 7mg/kg/day(max640mginitialdose) 7.5mg/kgoncedaily(Maximum640mginitialdose) administration at8amDAILY https://www.childrens.health.qld.gov.au/chq/health- Date ofBirth: Address: Given Names: Family Name: URN: ). Itisimportanttorecordwhetherthelinewasprimed viaasyringedriver(60mL/hr)( age appropriatemg/kgdose (Affix patientidentificationlabelhere) Please refertoNeonataldosing . 7.5mg/kg/day (max320mginitialdose) . toallow2and6hourpostdose ard Pharmacist). max ). Itisessentialfornursing Sex: unless patientisfluid .

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I TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN DO NOT WRITE IN THIS BINDING MARGIN II cm Page 2 of 5 F F

M M OR (hh:mm): 2 Sex: Sex: Syringe driver

Height: section). kg Burette

Other (specify):

. Consider patient’s clinical condition, . Consider patient’s (Affix patient identification label here) here) label label identification identification patient patient (Affix (Affix Dose (mg): . Dose changes should be in the order of targets Actual administration finish time Record management plan Record management Family Name:Family Name: Given Names:Given Names: Address:Address: Date of Birth: Date of Birth: URN: URN: Weight: Bronchiectasis Gentamicin

Mode of administration: after next dose (maximum 3 paired tests per week No

Yes Cystic Fibrosis Tobramycin

(hh:mm): 2

at a time. Tobramycin/Gentamicin A 10 minute discrepancy can result in a clinically significant dose error. minute discrepancy can result in a clinically significant dose error. 10 A Therapeutic Drug Monitoring Therapeutic post dose Aminoglycoside level in 7 days time and compare to baseline result. Aminoglycoside level in 7 days time post dose For critically ill OR renally impaired patients retest 2 hour and 6 hour levels in approximately 2 to 3 days time. For critically ill OR renally impaired patients retest 2 hour and 6 hour levels clearance with a 2 hour and 6 hour For non-critically ill patients (with stable renal function), recheck patient Repeat the 2 hour and 6 hour blood test per Consultant decision). The calculation from the AUC calculator is only a guide AUC calculator The calculation from the 1-2mg/kg for easy and accurate measurement). Consider ease of administration when finalising total dose (e.g. round Empiric target: AUC 70-90, Cmax >20mg/L, C24 <0.5mg/L AUC 70-90, Cmax >20mg/L, C24 <0.5mg/L Empiric target: cultured may inform the Cmax Directed therapy: Minimum inhibitory concentration (MIC) for micro-organism AMS Pharmacist advice. Seek ID specialist or targets to ensure therapeutic efficacy. Pseudomonas eradication: AUC 90-110, Cmax 25-35mg/L, C24 <0.5mg/L Cmax 25-35mg/L, C24 <0.5mg/L 90-110, AUC Pseudomonas eradication: AUC 80-100, Cmax 25-35mg/L, C24 <0.5mg/L Pseudomonas negative or chronic pseudomonas colonisation: Other indications (including Bronchiectasis) – Tobramycin/Gentamicin: Cystic Fibrosis – Tobramycin: Cystic Fibrosis – Tobramycin: a trough level prior. Document decision on this form ( Document decision on a trough level prior. be given. plan documented), prior to next dose (and no management Gentamicin results are not available Tobramycin/ If with or without taking pending results, or administer and discuss whether to withhold notify Doctor immediately Check Tobramycin/ Gentamicin levels before next dose is given, and whenever ‘2 and 6 hour post dose levels’ levels’ whenever ‘2 and 6 hour post dose levels before next dose is given, and Gentamicin Tobramycin/ Check form. indicated on medication prescribed dose can Doctor (or Pharmacist) to ensure not recorded, discuss results with If management plan Note:

When decision is to remain on current dose When dose change is indicated 2

• • • • • Dose recommendations are based on attainment of the microbiology results and concomitant drug therapy.

• THERAPEUTIC DRUG MONITORING TARGETS THERAPEUTIC DRUG MONITORING • PHARMACY USE ONLY USE PHARMACY venous access devices (CVAD), flush CVAD with Sodium chloride 0.9% 5-10mL, then draw back and flush CVAD venous access devices (CVAD), before taking sample. from CVAD, blood discard 5-10mL alter the interpretation of trough level results and accuracy of dose recommendations. alter the interpretation of trough reason on this form. please note details and occur, If administration duration/time variations from Central blood samples reduce risk of contamination when collecting Tobramycin/Gentamicin To Actual time blood taken (6-8 hours post start of infusion) T2 (hh:mm): post start of infusion) Actual time blood taken (6-8 hours can and blood sampling is essential as small deviations Accurate recording of times for administration Actual infusion start time T1 (hh:mm): post start of infusion) Actual time blood taken (2-3 hours Indication for therapy: Aminoglycoside: Date of blood tests: Line primed with drug: Nursing and Medical staff to complete Nursing and Medical staff to • • • Safety check before each dose: Safety check before 00007:658202_v4.00 - 03/2020 TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN DO NOT WRITE IN THIS BINDING MARGIN 00007:658202_v4.00 -03/2020 exacerbations: V. Aminoglycosides. Pediatr. Pulmonol.,48:1047–1061. Further reading: AUC Calculatoravailable: AUSLAB/AUSCARE Discussed withDrXPICUreg. Discussed withDrXPaedregOR AUC &Cmaxtargetsnotobtained, requiredoseincreasetoXmgandretest2&6hrlevel. For example: Record ManagementPlan–Date: Predicted C24(mg/L): Calculated AUC (mg/L*hr): Concentration at T1 (mg/L): PHARMACY USE ONLY Therapeutic DrugMonitoring  Tobramycin/Gentamicin Print andattachacopyofthe AUC calculationtothisformforscanningandfilingintoieMR AUC inrange,CmaxandC24good–remaincurrentdose,retest6hourlevel7days. Young etal(2013),Optimizationofanti-pseudomonalantibioticsforcysticfibrosispulmonary timescorrelatewithwardrecordedtimes:

http://qheps.health.qld.gov.au/rch/docs/pharmacy/AUC_cal.xls / Date ofBirth: Address: Given Names: Family Name: URN: Concentration at T2 (mg/L): Predicted C

(Affix patientidentificationlabelhere) Yes max (mg/L):

No Sex:

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I TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN DO NOT WRITE IN THIS BINDING MARGIN II cm Page 4 of 5 F F

M M OR (hh:mm): 2 Sex: Sex: Syringe driver

Height: section). kg Burette

Other (specify):

Mode of administration: after next dose (maximum 3 paired tests per week No

Yes Cystic Fibrosis Tobramycin

(hh:mm): 2

at a time. Tobramycin/Gentamicin A 10 minute discrepancy can result in a clinically significant dose error. minute discrepancy can result in a clinically significant dose error. 10 A Therapeutic Drug Monitoring Therapeutic For non-critically ill patients (with stable renal function), recheck patient clearance with a 2 hour and 6 hour For non-critically ill patients (with stable renal function), recheck patient and compare to baseline result. Aminoglycoside level in 7 days time post dose For critically ill OR renally impaired patients retest 2 hour and 6 hour levels in approximately 2 to 3 days time. For critically ill OR renally impaired patients retest 2 hour and 6 hour levels Consider ease of administration when finalising total dose (e.g. round for easy and accurate measurement). Consider ease of administration when finalising total dose (e.g. round Repeat the 2 hour and 6 hour blood test per Consultant decision). The calculation from the AUC calculator is only a guide AUC calculator The calculation from the 1-2mg/kg Empiric target: AUC 70-90, Cmax >20mg/L, C24 <0.5mg/L AUC 70-90, Cmax >20mg/L, C24 <0.5mg/L Empiric target: cultured may inform the Cmax Directed therapy: Minimum inhibitory concentration (MIC) for micro-organism AMS Pharmacist advice. Seek ID specialist or targets to ensure therapeutic efficacy. Pseudomonas eradication: AUC 90-110, Cmax 25-35mg/L, C24 <0.5mg/L Cmax 25-35mg/L, C24 <0.5mg/L 90-110, AUC Pseudomonas eradication: AUC 80-100, Cmax 25-35mg/L, C24 <0.5mg/L Pseudomonas negative or chronic pseudomonas colonisation: Other indications (including Bronchiectasis) – Tobramycin/Gentamicin: Cystic Fibrosis – Tobramycin: Cystic Fibrosis – Tobramycin: a trough level prior. Document decision on this form ( Document decision on a trough level prior. be given. plan documented), prior to next dose (and no management Gentamicin results are not available Tobramycin/ If with or without taking pending results, or administer and discuss whether to withhold notify Doctor immediately Check Tobramycin/ Gentamicin levels before next dose is given, and whenever ‘2 and 6 hour post dose levels’ levels’ whenever ‘2 and 6 hour post dose levels before next dose is given, and Gentamicin Tobramycin/ Check form. indicated on medication prescribed dose can Doctor (or Pharmacist) to ensure not recorded, discuss results with If management plan Note:

When decision is to remain on current dose When dose change is indicated 2 • • • • • Dose recommendations are based on attainment of the microbiology results and concomitant drug therapy.

• THERAPEUTIC DRUG MONITORING TARGETS THERAPEUTIC DRUG MONITORING •

PHARMACY USE ONLY USE PHARMACY alter the interpretation of trough level results and accuracy of dose recommendations. If administration level results and accuracy of dose recommendations. If administration alter the interpretation of trough reason on this form. please note details and duration/time variations occur, Actual time blood taken (6-8 hours post start of infusion) T2 (hh:mm): post start of infusion) Actual time blood taken (6-8 hours can and blood sampling is essential as small deviations Accurate recording of times for administration Actual infusion start time T1 (hh:mm): post start of infusion) Actual time blood taken (2-3 hours Indication for therapy: Aminoglycoside: Date of blood tests: Line primed with drug: Nursing and Medical staff to complete Nursing and Medical staff to • • • Safety check before each dose: Safety check before 00007:658202_v4.00 - 03/2020 TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN DO NOT WRITE IN THIS BINDING MARGIN 00007:658202_v4.00 -03/2020 exacerbations: V. Aminoglycosides. Pediatr. Pulmonol.,48:1047–1061. Further reading: AUC Calculatoravailable: AUSLAB/AUSCARE Discussed withDrXPICUreg. Discussed withDrXPaedregOR AUC &Cmaxtargetsnotobtained, requiredoseincreasetoXmgandretest2&6hrlevel. For example: Record ManagementPlan–Date: Predicted C24(mg/L): Calculated AUC (mg/L*hr): Concentration at T1 (mg/L): PHARMACY USE ONLY Therapeutic DrugMonitoring  Tobramycin/Gentamicin Print andattachacopyofthe AUC calculationtothisformforscanningandfilingintoieMR AUC inrange,CmaxandC24good–remaincurrentdose,retest6hourlevel7days. Young etal(2013),Optimizationofanti-pseudomonalantibioticsforcysticfibrosispulmonary timescorrelatewithwardrecordedtimes:

http://qheps.health.qld.gov.au/rch/docs/pharmacy/AUC_cal.xls / Date ofBirth: Address: Given Names: Family Name: URN: Concentration at T2 (mg/L): Predicted C

(Affix patientidentificationlabelhere) Yes max (mg/L):

No Sex:

F  Page 5of

I TOBRAMYCIN/GENTAMICIN THERAPEUTIC DRUG MONITORING DRUG THERAPEUTIC TOBRAMYCIN/GENTAMICIN