Correct!
4. The patient appears to have extremely high mortality risk and is at high risk for infection with MDR organisms.
Although the side effects of aminoglycosides weigh in the decision to administer them, the most immediate threat to this patient’s life is septic shock. The antibiotic most likely to cover the organism should be employed unless absolutely contraindicated.
The loading dose of a medication does not depend on its half-life, but rather on its volume of distribution, therefore a loading dose of aminoglycosides should not be reduced in patients with life threatening infections and renal failure. Renal failure will however require lengthening the time between doses. A pharmacy consultation can be helpful in this regard.
A loading dose of 15 mg/kg of amikacin was administered and the antibiotics started on admission continued. Infectious disease consultation was obtained. The consultant did not change the antibiotics (3), but added an order to continue amikacin 8.75 mg/kg every 24 hours with a pharmacy consult to monitor amikacin trough levels and adjust subsequent dosing.
A DNA probe of a blood culture specimen drawn on admission identified Klebsiella pneumoniae with CTX-M (ESBL) and NDM-1 (carbapenemase) genes within 27 hours of admission. Klebsiella pneumoniae grown out of blood and respiratory secretions, was resistant to all cephalosporin, carbapenem and beta-lactam antibiotics including ceftazidime/avibactam, ceftolozane/tazobactam, and meropenem/vaborbactam, but sensitive to all three aminoglycosides.
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