Background: Data on aminoglycoside (AG) pharmacokinetics (PK) in intermittent hemodialysis (iHD) is outdated; current practice employs more efficient iHD modalities. Once-daily AG are used to optimize treatment of resistant organisms including non-tuberculous mycobacterium (NTM). Currently recommended amikacin dosing (3-5 mg/kg post-iHD) is unlikely to obtain IDSA-recommended target Cmax for NTM (20-30mg/L). Recently, experts have suggested gentamicin dosed pre-iHD can attain maximal peak to optimize PK/PD goals; using iHD to decrease overall exposure to avoid toxicity. No PK data has described pre-iHD dosing strategy for high-dose amikacin, so it remains uncommonly practiced.
Methods: We describe a high-dose strategy of IV amikacin and PK monitoring (efficacy and toxicity) in 2 cases of peritoneal dialysis peritonitis caused by NTM. Amikacin was dosed at 7mg/kg on iHD days, given 4 hours pre-iHD to allow distribution. Amikacin levels were drawn: prior to iHD (peak); 4 hours post-iHD (trough); and prior to next dose administration (true trough to assess non-iHD clearance). PK analysis was performed assuming one compartment, linear kinetics.
Results: See Figure 1 and Figure 2
Conclusion: Pre-iHD amikacin 7mg/kg achieved IDSA-recommended Cmax for treatment of NTM peritonitis. Amikacin clearance with current iHD modalities was much more efficient than prior reports. High-dose, pre-iHD administration strategy successfully improved PK/PD parameters, allowing high Cmax, while decreasing overall amikacin exposure on non-iHD days. We suggest pre-iHD amikacin dosing for iHD patients who require high-dose therapy for optimal attainment of Cmax targets in serious infections.
J. Perl, None
E. Leung, None
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