Single-Dose Aminoglycosides for Urinary Tract Infections
Evaluating the evidence for single-dose aminoglycoside therapy as an alternative treatment for UTIs — a systematic review of 13 studies spanning 1978–1991.
Jimmy Pruitt
Clinical Pharmacist
1
Syst. Review
13,804
Patients
13
Included Studies
4
References
Urinary tract infections are most commonly caused by Enterobacteriaceae (E. coli, Proteus spp., Klebsiella spp., etc.) and other Gram-negative organisms. Barriers to traditional oral antibiotic therapy include increasing bacterial resistance, nonadherence rates approaching 60%, and medication access issues.
Broad-Spectrum Activity
Excellent activity against most uropathogens, including drug-resistant Enterobacteriaceae
Renal Concentration
Urinary concentrations 100-fold greater than plasma levels
Prolonged PAE
Post-antibiotic effect may persist for up to 72 hours
Single-Dose Safety
Toxicities may be limited with one-time administration; prevents access and adherence concerns
Key Definitions
Uncomplicated UTI
Non-pregnant women with no known anatomical/functional urinary tract abnormalities or comorbidities
Complicated UTI
All men, pregnant women, anatomical/functional abnormalities, indwelling catheters, renal diseases, diabetes
Cystitis
Infection confined to the bladder; symptoms of increased urinary urgency, frequency, and dysuria
Pyelonephritis
Infection extends beyond the bladder; cystitis symptoms plus fever, chills, flank and pelvic pain
Single-Dose Regimens
Gentamicin
5
mg/kg IV/IM once
Amikacin
15
mg/kg IV/IM once
Tobramycin
5
mg/kg IV/IM once
Relative Dosing
Weight-Based Dosing
[TBW < IBW]: Use TBW
[TBW 1x to 1.25x IBW]: Use IBW or TBW
[TBW > 1.25x IBW]: Use adjusted body weight
Adverse Effects
Considerations
Caution in renal impairment
Large volume for IM administration
Clinical Pearl
Aminoglycosides achieve urinary concentrations 100-fold greater than plasma levels. The post-antibiotic effect may persist up to 72 hours, making single-dose therapy a pharmacokinetically rational approach for uncomplicated lower UTIs.
Evidence at a Glance
94.5%
Microbiologic Cure
19%
30-Day Recurrence
0.5%
Adverse Effects
72%
E. coli Isolates
Safety signal: Only 64/13,804 (0.5%) reported adverse effects — primarily vestibular toxicity (53 pts) and nephrotoxicity (7 pts). No nephrotoxicity reported in studies using single-dose regimens with normal renal function.
| Parameter | Details |
|---|---|
| Design | Systematic review of 13 studies published from 1978 to 1991 (n=13,804 patients) |
| Inclusion |
Single-dose aminoglycoside with no concomitant antibiotic therapy Average patient: Pediatric female with acute uncomplicated cystitis secondary to E. coli with normal renal function, outpatient setting 72% of isolates were E. coli. Netilmicin most commonly used aminoglycoside. |
| Efficacy |
94.5% microbiologic cure
No difference vs comparators
No differences between pediatric- and adult-only studies. Patients with anatomical abnormalities less likely to achieve initial cure. |
| Recurrence |
19% (84/443) 30-day recurrence
In studies with minimum 30-day follow-up |
| Safety |
0.5% adverse effects (64/13,804)
Mainly vestibular toxicity (53 pts) and nephrotoxicity (7 pts) |
| Limitations |
Majority of patients (13,258/13,804) from one study Questionable generalizability (8 pediatric-only; 3 adult-only) Only 1 study with renal impairment patients; 2 with pyelonephritis; no sepsis/bacteremia Older studies not reflecting modern uropathogens; no comparison to nitrofurantoin or IV ceftriaxone No blinding; symptom data not reported; no assessment of future resistance |
Bottom Line
Consider use in patients with:
- Lower UTI (cystitis)
- No systemic signs/symptoms
- Normal renal function
- No urinary tract abnormalities
AND multiple of the following:
- Medication access issues
- Known medication nonadherence
- Multiple antibiotic allergies
- History of resistant organisms
- Unable to take oral medications
Single-dose aminoglycoside therapy may be a plausible treatment option in patients with cystitis.
Aminoglycosides can be administered via either the IV or IM route and do not necessarily require IV access. Gentamicin may be considered the preferred aminoglycoside based on frequency of use in studies.
The risk for adverse events with single-dose aminoglycosides is low, however, there are concerns for nephrotoxicity and ototoxicity.
Single-dose aminoglycoside should NOT be recommended as first-line therapy. It can be considered in patients with acute cystitis with normal renal function and multiple barriers to the standard of care.
- Bonkat G, Bartoletti RR, Bruyere F et al. EAU Guidelines on Urological Infections. Urological Infections. 2019.
- Uncomplicated Cystitis and Pyelonephritis (UTI). Clinical Infectious Diseases. 2011;52(5):e103–e120.
- Clinical Practice Guideline for the management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2019;68(10):e83–75.
- Goodlet KJ, Benhalima FZ, Nailor MD. A Systematic Review of Single-Dose Aminoglycoside Therapy for Urinary Tract Infection: Is It Time To Resurrect an Old Strategy? Antimicrob Agents Chemother. 2018 Dec 21;63(1):e02165–18.
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