What is the recommended intravenous (IV) dose of amikacin for children?

Amikacin Use in Children: Dosing and Administration

Yes, amikacin can be given to children intravenously, with a recommended dose of 15-30 mg/kg/day, administered either as a single daily dose or divided into 2-3 doses, with once-daily dosing preferred for efficacy and reduced toxicity. 1, 2

Recommended IV Dosing Regimens for Children

Standard Dosing Options

• 15-30 mg/kg once daily (preferred regimen) 1
• 7.5 mg/kg every 12 hours (divided dosing alternative) 2
• 5 mg/kg every 8 hours (three times daily alternative) 2
• 15-30 mg/kg three times per week for prolonged therapy to reduce cumulative toxicity 1

Special Considerations by Age

• Newborns: Loading dose of 10 mg/kg, followed by 7.5 mg/kg every 12 hours 2
• Infants under 1 year: 20 mg/kg/day total daily dose 3
• Children over 1 year: 15 mg/kg/day standard dose 3

Evidence Supporting Once-Daily Dosing

Once-daily dosing is superior to divided dosing in pediatric patients based on clinical outcomes and safety. 3, 4

• A randomized trial of 348 critically ill patients (including 141 pediatric patients) demonstrated 83% clinical cure with once-daily dosing versus 66% with twice-daily dosing (P=0.001) 3
• Nephrotoxicity occurred in only 21% with once-daily versus 35% with twice-daily dosing (P=0.05) 3
• A study of 56 pediatric patients using 20 mg/kg once daily achieved 98% satisfactory clinical results with no detected nephrotoxicity or ototoxicity 4
• Pharmacokinetic modeling in children aged 1-12 years showed that 20 mg/kg once daily provides higher probability of target attainment with lower toxicity than three-times-daily dosing 5

Critical Monitoring Requirements

Therapeutic Drug Monitoring

• Target trough level: <5 mg/L to prevent toxicity 1, 2
• Target peak level: 25-35 mg/L for daily dosing or 65-80 mg/L for three-times-weekly dosing 1
• Timing: Measure peak levels within the first week, trough levels weekly for 4 weeks, then every 2 weeks when stable 1
• Avoid: Peak concentrations above 35 mcg/mL and trough concentrations above 10 mcg/mL 2

Safety Monitoring

• Renal function: Monitor serum creatinine at baseline and regularly during therapy 2
• Auditory function: Baseline audiometry recommended, with intermittent monitoring during treatment 6
• Vestibular function: Clinical assessment for balance disturbances 6

Important Toxicity Considerations

Nephrotoxicity

• Accumulation occurs in renal impairment; adjust dose and/or frequency based on creatinine clearance 1
• More common with prolonged therapy and in elderly patients 1

Ototoxicity

• Irreversible vestibulocochlear nerve damage is the most serious adverse effect 1
• Auditory toxicity is more common than vestibular toxicity 1
• Risk increases with prolonged use and older age 1

Electrolyte Disturbances

• Monitor for hypocalcemia, hypomagnesemia, and hypokalemia 1, 6

Dosing Adjustments

Renal Impairment

• Reduce dosing frequency to every 2-3 days at 12-15 mg/kg 7
• For hemodialysis patients, administer after dialysis 7

Obesity

• Use ideal body weight plus 40% of excess weight for dose calculation 1
• Male ideal body weight (kg) = 50 + (2.3 × height in cm above 152.4)/2.54 1
• Female ideal body weight (kg) = 45.5 + (2.3 × height in cm above 152.4)/2.54 1

Duration of Therapy

• Usual duration: 7-10 days 2
• Limit treatment duration to short-term whenever feasible 2
• If treatment beyond 10 days is needed, re-evaluate and monitor amikacin serum levels, renal, auditory, and vestibular functions closely 2

Clinical Pitfalls to Avoid

• Do not use fixed 500 mg doses in children, as this ignores patient weight and risks underdosing with treatment failure 8
• Do not exceed 15 mg/kg/day total daily dose by all routes of administration 2
• Do not use every-other-day dosing for IV amikacin, as this is not supported by guidelines and may lead to inadequate levels 8
• Ensure clinical response within 3-5 days; if no response occurs, stop therapy and recheck antibiotic susceptibility 2