ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, July 1999, p.

15491555
0066-4804/99/$04.000
Copyright 1999, American Society for Microbiology. All Rights Reserved.

Vol. 43, No. 7

Prospective Evaluation of the Effect of an Aminoglycoside Dosing

Regimen on Rates of Observed Nephrotoxicity and Ototoxicity
MICHAEL J. RYBAK,1,2* BETTY J. ABATE,1 S. LENA KANG,1 MICHAEL J. RUFFING,1
STEPHEN A. LERNER,2 AND GEORGE L. DRUSANO3
The Anti-Infective Research Laboratory, Department of Pharmacy Services, Detroit Receiving Hospital and University
Health Center, College of Pharmacy and Allied Health Professions,1 and Department of Internal Medicine, Division of
Infectious Diseases, School of Medicine,2 Wayne State University, Detroit, Michigan 48201, and Division of Clinical
Pharmacology, Departments of Medicine and Pharmacology, Albany Medical College, Albany, New York 122083
Received 21 July 1998/Returned for modification 3 January 1999/Accepted 5 April 1999

The nephrotoxicity and ototoxicity associated with once-daily versus twice-daily administration of aminoglycosides was assessed in patients with suspected or proven gram-negative bacterial infections in a randomized, double-blind clinical trial. Patients who received therapy for >72 h were evaluated for toxicity. Patients
also received concomitant antibiotics as deemed necessary for treatment of their infection. Plasma aminoglycoside concentrations, prospective aminoglycoside dosage adjustment, and serial audiologic and renal status
evaluations were performed. The probability of occurrence of a nephrotoxic event and its relationship to doses
and daily aminoglycoside exposure served as the main outcome measurement. One hundred twenty-three
patients were enrolled in the study, with 83 patients receiving therapy for at least 72 h. For 74 patients plasma
aminoglycoside concentrations were available for analysis, and the patients formed the group evaluable for
toxicity. The primary infectious diagnosis for the patients who were enrolled in the study were bacteremia or
sepsis, respiratory infections, skin and soft tissue infections, or urosepsis or pyelonephritis. Of the 74 patients
evaluable for toxicity, 39 received doses twice daily and 35 received doses once daily and a placebo 12 h later.
Nephrotoxicity occurred in 6 of 39 (15.4%) patients who received aminoglycosides twice daily and 0 of 35
patients who received aminoglycosides once daily. The schedule of aminoglycoside administration, concomitant
use of vancomycin, and daily area under the plasma concentration-time curve (AUC) for the aminoglycosides
were found to be significant predictors of nephrotoxicity by multivariate logistic regression analysis (P <
0.001). The time to a nephrotoxic event was significantly influenced by vancomycin use and the schedule of
administration, as assessed by Cox proportional hazards modeling (P < 0.002). The results of the multivariate
logistic regression analysis and the Cox proportional hazards modeling demonstrate that both the probability
of occurrence and the time to occurrence of aminoglycoside nephrotoxicity are influenced by the schedule on
which the aminoglycoside is administered as well as by the concomitant use of vancomycin. Furthermore, this
risk of occurrence is modulated by the daily AUC for aminoglycoside exposure. These data suggest that
once-daily administration of aminoglycosides has a predictably lower probability of causing nephrotoxicity
than twice-daily administration.
phospholipases A1 and A2 by aminoglycosides results in the
formation of lamellar bodies which are postulated to cause
cellular toxicity (37). The method of uptake into PRTE cells is
closely linked to the rationale underlying the use of once-daily
dosing to delay the onset of nephrotoxicity. The uptake of
aminoglycosides is limited to the luminal border of the PRTE
cell. It is likely that they bind to the cell surface and are taken
up by pinocytosis, which is inherently limited to a maximal rate.
Consequently, no matter how much aminoglycoside is present
in the tubular lumen, only a maximal amount can be taken up
per unit of time. The administration of larger doses less frequently allows high concentrations of drug to be present in the
tubular lumen early in the dosing interval. Consequently, with
high concentrations of aminoglycosides in the tubular lumen,
when uptake is saturated, the rate of uptake is maximal and
thus is not increased with higher concentrations. Therefore,
much of the aminoglycoside bypasses the PRTE cell and is
excreted. Smaller amounts of the drug are present for longer
periods of time. The total amount of drug taken up by the cells
per 24 h is smaller, as seen from the data of Verpooten et al.
(39).
Traditionally, aminoglycosides have been administered in
two to three divided doses per day by intermittent infusion.
Numerous studies conducted with animals and humans have

The major limitation to the clinical use of aminoglycosides

continues to be concern for the development of nephrotoxicity.
Evidence from studies with animals and humans has demonstrated a correlation between the nephrotoxic effects of aminoglycosides and the accumulation of these drugs in the cortex
of the kidney (9, 23, 39). It is also evident that aminoglycoside
accumulation in the kidney may be related to the dosing schedule; i.e., administration of larger doses less frequently may
reduce the level of drug accumulation in the kidney cortex and
thereby may reduce the nephrotoxic potentials of aminoglycosides.
Aminoglycoside nephrotoxicity is thought to be centered in
the proximal renal tubular epithelial (PRTE) cells. Investigators have indicated that inhibition of phosphatidylinositol
* Corresponding author. Mailing address: The Anti-Infective Research Laboratory, Department of Pharmacy Services, Detroit Receiving Hospital and University Health Center, 4201 St. Antoine Blvd.,
Detroit, MI 48201. Phone: (313) 745-4554. Fax: (313) 993-2522. Email: mrybak@dmc.org.
Present address: Department of Pharmacy, Grace Hospital, Detroit, MI 48235.
Present address: Department of Pharmacy Practice, School of
Pharmacy, University of the Pacific, Stockton, CA 95211.
1549

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RYBAK ET AL.

demonstrated equal efficacy (5, 11, 12, 1416, 18, 2022, 2631,
34, 35, 38, 41) and nephrotoxicity (11, 12, 1416, 2022, 26, 27,
29, 31, 3335, 38, 39, 41) with once-daily dosing of aminoglycosides compared with those with conventional dosing. All
clinical studies to date have been unblinded. Moreover, many
patients have received therapy for short periods of time. Such
limited therapy may minimize toxicity and may thus obscure
any difference between the effects of different dosing schedules. Recently, five different investigations by meta-analysis
examined the data from the majority of published studies of
once- versus multiple-daily dosing of aminoglycosides (1, 3, 4,
25, 36). The results of those studies indicated that the rates of
toxicity with once-daily dosing were less than or equal to those
with multiple-daily dosing. Furthermore, one of the analyses
indicated a more favorable clinical outcome with once-daily
dosing with dosed aminoglycosides compared with that from
multiple-daily dosing (25). Meta-analysis may point the way to
a correct hypothesis, but the ultimate proof of that hypothesis
is still in the realm of the prospective randomized trial. We
designed and carried out a prospective, randomized, doubleblind study of once-daily aminoglycoside therapy compared
to twice-daily therapy to examine toxicity in patients being
treated for at least 72 h for suspected gram-negative bacterial
infections.
MATERIALS AND METHODS
One hundred twenty-three patients admitted to the Detroit Receiving Hospital and University Health Center for bacteremia or sepsis, respiratory infections,
skin and soft tissue infections, or urosepsis or pyelonephritis that were suspected
to be due to gram-negative pathogens and for whom aminoglycoside therapy was
required were enrolled in the study. Patients were identified for screening by
physician order for an aminoglycoside. Of these patients, 123 were enrolled in
the study on the basis of the following criteria; patients enrolled were greater
than 18 years of age, had suspected infection for which an aminoglycoside was
prescribed, had received no more than two aminoglycoside doses for the current
infection, and were expected to receive therapy for at least 3 days. Patients were
excluded if they had a serum creatinine concentration of 2.4 mg/dl, weighed
30% above their ideal body weight, had a history of hypersensitivity to any
aminoglycoside, had tinnitus, deafness, or vestibular disturbances, or were pregnant, neutropenic (neutrophil count, 1,000/mm3), suspected of having meningitis, or in shock.
The protocol was approved by the Human Investigation Committee of Wayne
State University, and informed consent was obtained from each patient or guardian. Patients were stratified by disease state (bacteremia or sepsis, respiratory
infection, skin and soft tissue infection, or urosepsis or pyelonephritis) and were
then randomly assigned by use of a random-numbers table to either dosing every
12 h as described below or dosing by once-daily administration of the entire daily
dose of aminoglycoside, followed 12 h later by 100 ml of 5% dextrose in water as
a placebo. Aminoglycoside doses were diluted in 100 ml of 5% dextrose in water.
Drug and placebo doses were administered over 1 h. Both the patients and the
physicians remained blinded to the treatment. Patients were also treated with
beta-lactam or other antimicrobial agents as deemed necessary by their physicians.
Aminoglycoside dosing was individualized for both groups and was guided by
targeted peak and trough concentrations in serum on the basis of the patients
individual pharmacokinetic parameters and standard equations (40). For the
twice-daily dosing group, target peak concentrations in serum were 8 to 10
mg/liter for those with respiratory infections and 5 to 6 mg/liter for those with all
other indications for gentamicin and tobramycin treatment, with trough concentrations of 2.0 mg/liter. For patients who received amikacin, peak concentrations in serum were 30 to 40 mg/liter for those with respiratory infections and 20
to 30 mg/liter for all other patients. Desired trough amikacin concentrations were
10.0 mg/liter. Target peak concentrations of gentamicin or tobramycin in serum concentrations for the once-daily dosing group were 16 to 20 mg/liter for
those with respiratory infections and 10 to 12 mg/liter for patients with other
infections. The desired peak serum amikacin concentrations were 60 to 80
mg/liter for patients with respiratory infections and 40 to 60 mg/liter for all
others. The desired trough concentrations for once-daily dosing were targeted to
be below 1.0 mg/liter. These target concentrations were based on doubling of the
conventional target ranges for the Detroit Receiving Hospital and University
Health Center (24). Initial dosing was based on population parameters in conjunction with the patients calculated creatinine clearance and estimated ideal
body weight. After serum aminoglycoside levels were obtained, dosing regimens
were adjusted to maintain peak and trough concentrations in the targeted ranges.
All patients were monitored daily by the unblinded pharmacokinetic consultation

ANTIMICROB. AGENTS CHEMOTHER.

service. For patients in both groups three blood samples were drawn for determination of the aminoglycoside concentration after the administration of active
doses (3rd, 7th, and 11th doses) and weekly thereafter. In addition, other determinations were made if deemed clinically necessary (e.g., for diminished renal
function). Serum sampling times were 0.5, 8.0, and 10.5 h after the end of the 1-h
infusion. Peak concentrations (end of infusion) and trough concentrations (at 12
and 24 h for groups who received aminoglycosides twice and once daily, respectively) were extrapolated by using a one-compartment equation with data for the
serum samples obtained at the various times. Concentrations in serum were
released only to unblinded pharmacists and were not reported in the patients
medical record.
Patient histories including the disease state that required aminoglycoside therapy, underlying medical conditions, and other drug therapies were obtained from
each patient and the medical records. All patients were classified by the Acute
Physiology and Chronic Health Evaluation (APACHE II) score (17). Creatinine
clearance was calculated by the method of Cockroft and Gault (8). Lean body
weight was used in the calculation of creatinine clearance for obese patients.
Patients who received an aminoglycoside for at least 72 h and for whom plasma
aminoglycoside concentration-time data were available were considered evaluable for nephrotoxicity. The serum creatinine concentration was obtained for
each patient at the baseline (the lowest serum creatinine concentration within
the period from 24 h before to 48 h after the initiation of therapy), on days 2, 4,
6, and 9, and then twice weekly or sooner if it was deemed clinically necessary.
Nephrotoxicity was defined as an increase in the baseline serum creatinine
concentration of 0.5 mg/dl or a 50% increase, whichever was greater, on two
consecutive occasions any time during therapy or up to 1 week after the cessation
of therapy (19). Nephrotoxicity was assessed by the same blinded investigator.
Audiologic testing was performed at the baseline (within 72 h of the start of
therapy), weekly thereafter or sooner if it was deemed clinically necessary, and
after the cessation of therapy. Pure-tone audiometry over the frequency range of
500 to 8,000 Hz (at the series of doubling frequencies and also at 3000 and 6,000
Hz) was performed for each ear by a certified audiologist in the audiologic
laboratory or at the patients bedside. Testing consisted of both air and bone
conduction measurements and was performed with instruments calibrated to the
American National Standards (ANSI S36-1969) specifications for audiometers.
Vestibular function was not tested. Hearing impairment was evaluated by using
the criteria of the American Academy of Otolaryngology Committee on Hearing
and Equilibrium (2). All audiograms were interpreted by the same blinded
investigator. Ototoxicity was defined as a decrease in auditory threshold of at
least 15 dB at two adjacent tested frequencies in one or both ears.
Statistical analysis for patient characteristics and pharmacokinetic parameters
was performed by the Mann-Whitney U rank sum test for unpaired data. The
Fisher exact test was used for comparison of proportions. Data are reported
as means standard deviations, and tests were performed at the 5% level of
significance. Data were analyzed with Quattro Pro 5.0 for Windows (Borland
International, Scotts Valley, Calif.) and SYSTAT 5.0 for Windows (SYSTAT
Inc., Evanston, Ill.).
For the multivariate logistic regression analysis for nephrotoxicity, seven variables were examined. Days of therapy (DOT), area under the plasma concentration-time curve (AUC), and cumulative AUC (CumAUC; calculated as AUC
DOT) were treated as continuous variables. Site of infection (Site), Vancomycin
use (Vanco), amphotericin B use (AmphoB), and schedule (Sched) were treated
as categorical variables. Peak and trough concentrations were not evaluated
separately. The hypothesis of this trial was that the dosing interval affects the
probability of aminoglycoside toxicity. The peak concentration and the trough
concentration are covariate with schedule (administration of the whole dose
once daily will give higher peaks and lower troughs than administration of half of
the dose every 12 h). We therefore decided to test the primary hypothesis that
the dosing schedule is linked to the occurrence of nephrotoxicity.
The occurrence or absence of nephrotoxicity was coded as 1 or 0, respectively.
The probability of occurrence of nephrotoxicity was modeled through the use of
logistic regression with the logistic regression module of SYSTAT. Each covariate was examined univariately. Model building was approached in the following
way: the covariate, which was most significant when tested univariately, was used
as the base model. Other model covariates were tested for model expansion, one
by one, in the order of the univariate significance. Because a maximum-likelihood estimator was used, the significance of model expansion was determined by
the likelihood ratio test. Twice the likelihood difference for the competing
models was referred to the 2 distribution with the appropriate number of
degrees of freedom for determination of significance.
We generated our hypothesis from data from previous studies with animals
and humans, which demonstrated that schedule of administration influences the
daily rate of uptake of aminoglycoside into the PRTE cell. This implies that
once-daily administration will not protect from nephrotoxicity indefinitely but
will delay the development of toxicity. We decided to test the hypothesis that
schedule of drug administration also influenced the time to occurrence of the
nephrotoxicity. Kaplan-Meier analysis was performed with stratification for dosing schedule. In addition, the same covariates detailed above were examined for
their ability to influence the time to occurrence of nephrotoxicity with a Cox
proportional hazards model. Model building proceeded as described above. In
this analysis, schedule of administration was used as a stratification variable in all
the analyses, and the effect of other covariates was examined by Cox modeling.

VOL. 43, 1999

TOXICITY OF AMINOGLYCOSIDES GIVEN ONCE OR TWICE DAILY

TABLE 1. Baseline characteristics of evaluable patientsa

Twice-daily
dosing group

Once-daily
dosing group

39

35

24/15

20/15

Age (yr)
Mean SD
Range

44.7 13.0
2383

47.3 15.8
2281

Wt (kg)
Mean SD
Range

72.2 17.0
46124

70.5 12.7
50108

5.7 5.1
019

5.6 4.7
021

3
19
7
10

4
11
9
11

0.9 0.3
0.41.5

1.0 0.3
0.51.9

Parameter

Total no. of patients

Sex (no. of males/no. of females)

APACHE II score
Mean SD
Range
Primary site of infection or infection
Bacteremia or sepsis
Skin and soft tissue
Respiratory
Urosepsis or pyelonephritis
Baseline serum creatinine concn (mg/dl)
Mean SD
Range

a
No statistically significant differences were present between the two treatment groups.

Schedule of administration was tested for significance as a stratification variable

by a Tarone-Ware test. In addition, a cumulative log hazards plot was examined
to see whether schedule was most appropriately used as a stratification variable
or as a covariate in the Cox proportional hazards model analysis.

RESULTS
Of a total of 123 patients enrolled in the study, 83 patients
received therapy for at least 72 h; for 74 patients plasma aminoglycoside concentrations were available for analysis, and
these patients formed the group evaluable for toxicity; 39 received doses twice daily and 35 received doses once daily. No
patient discontinued therapy due to side effects attributed to
an aminoglycoside. Of the patients not evaluable for toxicity,
the majority were changed to some other antibiotic therapy
before completing the minimum 72 h of aminoglycoside therapy: 14 of 23 (61%) were in the twice-daily dosing group and
17 of 26 (65%) were in the once-daily dosing group. Two patients in each group died before 72 h of treatment. One patient
in the twice-daily dosing group was withdrawn because of an

1551

Ethics Committee decision to withdraw life support measures.

Two patients who received aminoglycosides twice daily and
one patient who received the drug once daily were receiving an
aminoglycoside for prophylaxis treatment, and one patient in
the once-daily dosing group was mistakenly enrolled after having received more than two prior doses of gentamicin. For the
remaining patients plasma concentration-time data were not
available.
Clinical characteristics for the 74 evaluable patients are
summarized in Table 1. At the baseline the groups were comparable with respect to sex, age, weight, infectious disease
diagnosis, serum creatinine clearance, and serum creatinine
concentration. Two patients in the twice-daily dosing group
and three patients in the once-daily dosing group were greater
than 70 years of age. The majority of patients in both groups
were treated for skin and soft tissue infections.
Peak and trough aminoglycoside concentrations for the
evaluable patients are presented in Table 2. Data for patients
who received either gentamicin or tobramycin were combined.
For patients who received amikacin, the AUC was divided by
4, and the data were included in the logistic regression analysis.
Average concentrations were derived by taking the average of
the mean concentration for each patient. As expected, peak
and trough concentrations in serum were significantly different
(P 0.0001) for the two dosing groups. Average daily doses
were 4.3 1.1 mg/kg of body weight with twice-daily dosing
versus 6.1 0.8 mg/kg with once-daily dosing for patients with
respiratory infections and 3.6 0.7 mg/kg with twice-daily
dosing versus 3.9 0.7 mg/kg with once-daily dosing for patients with all other infections combined. Three patients in the
twice-daily dosing group experienced trough serum gentamicin
or tobramycin concentrations above 2.0 mg/liter, whereas one
patient in the once-daily dosing group experienced a trough
concentration in serum above 2.0 mg/liter. One patient with
twice-daily dosing (bacteremia) and three patients with oncedaily dosing (pneumonia) never achieved the targeted peak
concentrations in serum.
Thirty-four of the 74 (46%) evaluable patients had bacteriologically documented infections. A wide variety of organisms
were cultured. Escherichia coli (n 12) was the most commonly isolated organism in each group. Other major organisms
included Acinetobacter baumannii (n 4), Pseudomonas aeruginosa (n 5), Klebsiella species (n 4), Enterococcus species
(n 5), and Staphylococcus aureus (n 2). Bacteremia was
more common in the once-daily dosing group (seven versus
three patients), and polymicrobial infections were more common in the twice-daily group (four patients versus one patient).
Patients in both groups received an average of one addi-

TABLE 2. Pharmacokinetic parameters for evaluable patients receiving gentamicin, tobramycin, or Amikacin
Gentamicin or tobramycin
Infection or site
of infection

Twice-daily dosing group

Once-daily dosing group

Peak
concn
(mg/liter)

Trough
concn
(mg/liter)

Peak
concn
(mg/liter)

Trough
concn
(mg/liter)a

No. of
patients

7.7 1.3
6.5 1.9
5.7 1.7
6.2 1.9

1.5 1.1 8 (5, 3)b 14.3 3.7

1.1 0.4 4 (2, 2)b 10.7 0.9
0.9 0.7 11 (7, 4)b 10.8 3.2
0.9 0.9 10 (8, 2)b 9.7 2.7

0.6 0.6
0.1 0.0
0.1 0.2
0.2 0.2

0
0
2
1

No. of
patients

Respiratory tract
7 (3, 4)b
Bacteremia or sepsis 3 (3)c
Skin or soft tissue
17 (13, 4)b
Urosepsis or pyelo9 (6, 3)b
nephritis
a
b
c

Amikacin

No. of
patients

Twice-daily dosing group

Trough concentrations at 24 h were estimated for patients receiving once-daily therapy.

Values in parentheses are numbers of patients who received gentamicin and tobramycin, respectively.
The value in parentheses is the number of patients who received gentamicin.

Peak
concn
(mg/liter)

Trough
concn
(mg/liter)

25.2 3.3 6.1 2.5

20.1
0.5

Once-daily dosing group

No. of
patients

1
0
1
0

Peak
concn
(mg/liter)

Trough
concn
(mg/liter)a

85.7

12.4

32.1

0.04

1552

RYBAK ET AL.

ANTIMICROB. AGENTS CHEMOTHER.

TABLE 3. Outcomes for evaluable patientsa

Dosing
group

Once daily
Twice daily
a
b
c

Change in
serum creatinine
concn (mg/dl)b

Cumulative dose

Duration of
therapy (days)

Amikacinc

Gentamicin and tobramycin

Mean SD

Range

Mean SD

Range

No. of
patients

Mean SD
dose (mg)

Dose range
(mg)

No. of
patients

Mean SD
dose (mg)

Dose range
(mg)

0.2 0.4
0.1 0.2

02.1
00.5

8.2 6.2
10.6 9.7

339
352

36
33

2,133 2,233
3,110 2,619

72013,600
80013,400

3
2

11,250 3,470
16,500 10,750

7,00015,500
5,75027,250

No statistically significant differences were present between the two treatment groups.
Change in serum creatinine (peak serum creatinine concentration) (baseline creatinine concentration).
Data were not available for one patient who received amikacin.

tional antibiotic during the study period. Most patients received a beta-lactam as concomitant therapy. The type of
beta-lactam therapy was similar between the two groups and
consisted of the following for the twice- and once-daily dosing
groups: ampicillin, 10 and 11 patients, respectively; ampicillinsulbactam, 1 and 2 patients, respectively; cefazolin, 7 and 5
patients, respectively; imipenem, 2 and 2 patients, respectively; nafcillin, 0 and 1 patients, respectively; piperacillin, 11
and 8 patients, respectively; and ticarcillin-clavulante, 1 and 2
patients, respectively. Eleven patients received concomitant
vancomycin therapy (seven and four patients in the twice-daily
and once-daily aminoglycopeptide dosing groups, respectively). One patient in each group received amphotericin B. No
statistically significant differences were noted for the groups
with respect to baseline APACHE II score, change in serum
creatinine concentration, duration of therapy, cumulative dose,
or mean total daily dose (Tables 1 and 3). Overall, the majority
of evaluable patients defervesced during the study and were
discharged to home or rehabilitation with oral antimicrobial
therapy. One patient in the twice-daily dosing group died during the study period (post-72 h). Soon after enrollment in the
study, this patient developed multi-organ system failure. Efficacy was not evaluated in this comparative study.
According to our definition, 6 of 39 patients (15.4%) in the
twice-daily dosing group and 0 of 35 patients in the once-daily
dosing group developed nephrotoxicity. This difference was
significant when tested by the Fisher exact test (P 0.026).
Toxicity was observed to begin 8.8 3.4 days after the start of
treatment in the twice-daily dosing group.
The results of logistic regression analyses performed univariately are summarized in Table 4. Only the schedule of
administration, vancomycin use, and daily AUC of aminoglycoside were significant in affecting the probability of nephrotoxicity. All were significant in the model-building process,
as assessed by likelihood ratios. The final parameter values are
displayed in Table 5.
The probability of nephrotoxicity as a function of AUC is
displayed in Fig. 1A and B for once-daily and twice-daily administration, respectively, with and without vancomycin use.
A Kaplan-Meier analysis demonstrated that schedule of administration (primary hypothesis) significantly influenced time
to nephrotoxicity (Log-rank test/mantel variant, P 0.006; logrank test/Breslow-Gehan variant, P 0.026). Because schedule of administration influenced time to nephrotoxicity, this
was retained as a stratification variable in all subsequent Cox
proportional hazards modeling studies.
The parameters from the univariate Cox proportional hazards models (with stratification for schedule) are displayed in
Table 6. Because the final model contained only vancomycin
use with schedule of administration as a stratification variable,
the final parameter value for vancomycin coadministration is
presented in Table 6.

Twenty-two patients, 10 with twice-daily dosing and 12 with

once-daily dosing, received two or more audiometric evaluations during and after treatment and were eligible for statistical
analysis. Of these patients, one who received twice-daily aminoglycoside therapy met the criteria for ototoxicity.
DISCUSSION
Extensive data from animal models and clinical studies indicate that once-daily dosing of aminoglycosides results in
lower accumulation rates per day in the PRTE cell. Whether
this would result in lower rates of aminoglycoside-associated
nephrotoxicity was the central question posed in this study.
Several studies with patients have demonstrated no significant
difference in efficacy (5, 11, 12, 1416, 18, 2022, 2631, 34, 35,
38, 41) and nephrotoxicity (11, 12, 1416, 2022, 26, 27, 29, 31,
3335, 38, 39, 41) between conventional and once-daily regimens of aminoglycoside dosing. These studies were, by and
large, underpowered to test the hypothesis of lower nephroTABLE 4. Logistic regression analysis of factors univariately
affecting the probability of aminoglycoside nephrotoxicitya
Standard
error

Covariate

Constant

Estimate

Site
Skin or soft tissue
Respiratory tract
Urosepsis or pyelonephritis
Bacteremia or sepsis

2.639

0.732
0.0
0.069
0.357
1.723

1.266
1.259
1.112

AUC

4.751

1.309
0.031

0.015

DOT

2.614

0.017

0.595
0.035

Sched
QD
Q12h

30.202

CumAUC

2.911

Vanco
Use
Use

3.418

AmphoB
Use
Use

2.595

0.0
1.822
0.001
0.719
0.0
2.858
0.464
0.0
2.595

P value

0.1

0.444

0.04
0.1
0.004

28.497
0.597
0.0004

0.1
0.002

0.954
0.1
1.488

Abbreviations: Sched, schedule, i.e., once-daily (QD) versus twice-daily

(Q12h) aminoglycoside administration; CumAUC, cumulative AUC, calculated
as AUC DOT; Vanco, use of systemic vancomycin; AmphoB, use of systemic
amphotericin B; Use, nonuse; Use, use.

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TOXICITY OF AMINOGLYCOSIDES GIVEN ONCE OR TWICE DAILY

1553

TABLE 5. Final model from multivariate logistic regression analysis

of factors affecting the probability of aminoglycoside nephrotoxicitya
Covariate

Constant

Vanco
Use
Use

37.239

Sched
QD
Q12h
AUC
a

Estimate

Standard error

2.482

0.0
3.531

1.411

0.0
30.757

0.001

0.049

0.026

P value

0.000065

Covariates and other abbreviations are as defined in footnote a of Table 4.

toxicity as a function of once-daily dosing, and most importantly, all were unblinded. However, a meta-analysis investigation by Barza et al. (4) has demonstrated that examination of
data from multiple studies demonstrates a difference in the
rate of aminoglycoside nephrotoxicity in favor of the oncedaily dosing group. Munckhof et al. (25), using a similar metaanalysis approach to data from published once-daily versus
multiple-daily aminoglycoside dosing studies (2,881 patients),
found equal rates of nephrotoxicity between the two regimens
but demonstrated a more favorable clinical outcome (P
0.027) with once-daily administration of these drugs. More
recently, three additional meta-analyses have evaluated oncedaily versus multiple-daily dosing of aminoglycosides. None of
those studies found differences in efficacy, and all studies reported similar rates of toxicity between once-daily and multiple-daily aminoglycoside dosing (1, 3, 36).
Our study represents the first prospective, double-blind evaluation of this question. We found that once-daily dosing did,
indeed, alter the risk of aminoglycoside nephrotoxicity. The
factors identified in the logistic regression analysis as altering
the probability of occurrence of nephrotoxicity and the factors
that affect the time to nephrotoxicity, as identified in the Cox
proportional hazards model, are concordant with each other
and with the findings with animal models.
Examination of the data of terBraak et al. (35) demonstrates
that once-daily dose administration and multiple-daily dose
administration each will ultimately produce toxicity. What one
purportedly gains from single-daily-dose administration is a
lower daily intracellular accumulation rate, consistent with the
clinical findings of Verpooten et al. (39) and the animal model
data of Wood et al. (41). Therefore, the once-daily dosing
schedule should provide a longer time of administration until
the threshold for toxicity is met. This is precisely what is seen
in our data, in which the AUC primarily drives the probability
of nephrotoxicity but is modulated by the schedule of administration and the concurrent use of vancomycin. More explicitly, the time to nephrotoxicity was affected by both the schedule of administration and vancomycin use in the Cox model.
The concurrent use of vancomycin plus an aminoglycoside
and the effect on the development of nephrotoxicity have been
areas surrounded by controversy (7, 32). The use of vancomycin in this study was not controlled, and the effect of its concurrent use on nephrotoxicity was not the primary hypothesis
being tested. As such, conclusions drawn from these data need
to be viewed with caution. Nevertheless, both multivariate
analyses indicated that concurrent vancomycin use significantly
affects the patients probability of developing nephrotoxicity
and shortening the time to its occurrence. While this finding
needs to be validated prospectively, clinicians would be prudent to monitor intensively the renal functions of patients who
are receiving both agents.

FIG. 1. (A) Curve of probability of development of aminoglycoside nephrotoxicity for patients receiving the drug on a twice-daily basis as estimated by
multivariate logistic regression analysis. The probability rises as a function of
increasing daily exposure to aminoglycoside, as indexed to the AUC. Concurrent
vancomycin use provides a marked increase in the probability of nephrotoxicity
for equivalent exposure to aminoglycosides, as indexed to the daily AUC. (B)
Once-daily administration shifts the curves of probability of nephrotoxicity as
influenced by daily aminoglycoside AUC to the right.

Amphotericin B use was not linked to the occurrence of

nephrotoxicity in any of the analyses. This is almost certainly
because of the small number of patients who received this drug
in our study. One of the patients in the twice-daily administration group received both vancomycin and amphotericin B and
developed nephrotoxicity. Elimination of data for this patient
from the data set changed none of the factors identified in
either the logistic regression analysis or the Cox model as
influencing the risk of nephrotoxicity.
Furthermore, all studies of once-daily dosing of aminoglycosides with patients to date have been unblinded. In contrast,
TABLE 6. Cox proportional hazard model analysis of factors
univariately affecting the time to aminoglycoside nephrotoxicitya
Covariate

Estimate

Standard
deviation

2 log likelihood
difference

P value

Site of infection
AUC
DOT
CumAUC
Vanco
AmphoB

1.102
0.024
0.041
0.0005
2.980
0.574

0.477
0.014
0.071
0.00079
1.122
1.191

6.076
2.766
0.418
0.471
9.508
0.210

0.014
0.096
0.1
0.1
0.002
0.1

a
Schedule of administration was used as a stratification variable for all analyses. See footnote a of Table 4 for definitions of covariates.

1554

RYBAK ET AL.

this study randomized patients to either twice-daily therapy or

once-daily therapy with a placebo infusion 12 h following the
administration of each active dose. Concentrations in serum
were not reported in the patients medical report during the
study period. This design allowed both the patient and the
health care givers (physicians and nurses) to remain blinded to
prevent investigator bias.
Nephrotoxicity developed in six patients in the twice-daily
dosing group but in none of the patients in the once-daily
dosing group. The serum creatinine concentrations for two of
these patients in the twice-daily dosing group returned to the
baseline before discharge from the hospital. Although the sample size is small, there was an equal distribution of males and
females among the patients who experienced nephrotoxicity.
To date, only one prospective study has reported a significant
decrease in the incidence of nephrotoxicity in patients treated
with aminoglycosides once daily compared to that in patients
treated thrice daily. Prins et al. (29) observed a 5% (n 40)
incidence of nephrotoxicity in patients receiving once-daily
therapy versus a 24% (n 45) incidence in patients receiving
an aminoglycoside three times daily. In their study, patients
were also evaluable if they received 72 h of therapy. These data
are quite consistent with the rates observed in the present
study. Prins et al. (30) have also recently reported no difference
in the rate of nephrotoxicity associated with once-daily gentamicin therapy (6.9%) versus that associated with once-daily
netilmicin therapy (14.5%). In the absence of compelling data
suggesting differences among aminoglycosides in their nephrotoxic potentials, we felt free to consider patients regardless
of which aminoglycoside was used.
The use of the terminology once-daily or single-daily
aminoglycoside therapy might be misleading. It is important to
stress the concept of achieving high peak concentrations in
serum rapidly and allowing concentrations to fall substantially
below 2.0 mg/liter prior to administration of the next dose.
Some patients in whom the aminoglycoside half-life is short
will experience long periods during which subinhibitory concentrations go beyond the postantibiotic effect and may require
dosing intervals shorter than 24 h, but this will require further
study. For patients with slower elimination rates, it may not be
appropriate to administer high doses of aminoglycosides on a
once-daily basis. Studies have documented the need for larger
initial doses of aminoglycosides in critically ill patients to
achieve the desirable peak concentrations (40). This concern
would be especially important with once-daily aminoglycoside
dosing regimens.
The debate on whether once-daily aminoglycoside administration has value for the treatment of patients with infection
continues to be voiced in the current literature, increasing the
value of our investigation (6, 13). We have shown that, as predicted from data from animal models, single-daily-dose aminoglycoside administration, when applied to patients with a
normal baseline renal function, is significantly less toxic than a
more fractionated schedule. Although we intended to analyze
the impact of dosing schedule on ototoxicity as well, the actual
incidence in our study was too low to analyze the data in terms
of ototoxicity. The potential for lowering the risk of ototoxicity
from aminoglycosides via once-daily aminoglycoside administration is important and should be further investigated. As long
as once-daily dosing of an aminoglycoside is at least as efficacious as conventional dosing, it clearly brings benefit to the
patient in terms of toxicity avoidance and added convenience,
especially for outpatient therapy. Furthermore, this therapeutic approach is more economical, since it produces less toxicity,
which is highly costly (10), and requires less disposable equipment (e.g., syringes and intravenous supplies) and labor time

ANTIMICROB. AGENTS CHEMOTHER.

for administration and fewer determinations of serum drug

concentrations. On the basis of the results of this prospective
study, for patients with normal renal function, we recommend
that clinicians give serious consideration to the use of singledaily dosing for this class of anti-infective agents as a way of
ameliorating the nephrotoxicity attendant to aminoglycoside
administration.
ACKNOWLEDGMENTS
We gratefully acknowledge the help of Diane Cappelletty, College
of Pharmacy, Wayne State University; Shirley Palmer, Department of
Pharmacy Practice, Medical College of Virginia School of Pharmacy,
Richmond; Donald Levine, Department of Internal Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University; and Sabina Schwan and William Rintelmann, Department of
Otolaryngology, Detroit Receiving Hospital and University Health
Center.
This research was supported by the time and effort of the investigators involved and the institution in which the research was performed
and did not receive any outside financial support.
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