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tobramycin
generic
Black Box Warnings .
Nephrotoxicity
acute kidney injury incl. acute renal failure can occur; incr. risk w/ incr. serum trough levels, high peak levels (>12 mcg/mL), total cumulative dose, advanced age, volume depletion, concurrent or sequential nephrotoxic agents; avoid concurrent and/or sequential nephrotoxic agents; monitor serum levels and renal fxn in all pts during tx; decr. dose or D/C if renal impairment occurs
Ototoxicity
irreversible auditory and vestibular toxicity can occur and may cont. to develop after drug D/C; incr. risk w/ high serum levels, prolonged tx, renal impairment, concurrent or sequential nephrotoxic or ototoxic agents, extremes of age; avoid concurrent and/or sequential ototoxic agents; monitor auditory and vestibular toxicity s/sx; reduce dose or D/C if renal impairment occurs; D/C if ototoxicity occurs
Neuromuscular Blockade
assoc. w/ aminoglycoside use; monitor sx during tx; incr. risk w/ underlying neuromuscular disorders (incl. myasthenia gravis), concomitant neuromuscular blockers
Embryo-Fetal Toxicity
aminoglycosides can cause fetal harm when admin. to pregnant women; advise pt of potential hazard to fetus if used during pregnancy or if pt becomes pregnant during tx
Adult Dosing .
Dosage forms: INJ
infections, bacterial
- [conventional interval dosing]
- Dose: 1-1.7 mg/kg/dose IM/IV q8h; Info: use adjusted wt of IBW + 0.4 x (ABW - IBW) in obese pts; adjust dose based on serum levels
- [extended interval dosing]
- Dose: 5-7 mg/kg/dose IV q24h; Info: not indicated in pregnancy, burns, ascites, obesity, neutropenia or endocarditis; use adjusted wt of IBW + 0.4 x (ABW - IBW) in obese pts; adjust dose based on random serum levels and nomogram
pneumonia, hospital-acquired or ventilator-assoc.
- [5-7 mg/kg/dose IV q24h x7 days]
- Info: may extend duration based on clinical response; refer to IDSA guidelines; use adjusted wt of IBW + 0.4 x (ABW - IBW) in obese pts; adjust dose based on serum levels
resp. infections, cystic fibrosis pts (off-label)
- [conventional interval dosing]
- Dose: 2.5-3.5 mg/kg/dose IV q8h; Info: use adjusted wt of IBW + 0.4 x (ABW-IBW) in obese pts; adjust dose based on serum levels
- [extended interval dosing]
- Dose: 10-12 mg/kg/dose IV q24h; Info: use adjusted wt of IBW + 0.4 x (ABW-IBW) in obese pts; adjust dose based on serum levels
renal dosing
- [non-cystic fibrosis, conventional interval dosing]
- CrCl 10-50: give usual dose q12-24h; CrCl <10: give usual dose x1, then redose if serum levels <1-2 mg/mL; Info: adjust dose, frequency based on serum levels
- HD: give usual dose x1, then redose after dialysis if serum levels <1-2 mg/mL; no supplement; PD: not defined; Info: adjust dose, frequency based on serum levels
- [non-cystic fibrosis, extended interval dosing]
- CrCl 30-60: adjust frequency based on random serum levels and nomogram; CrCl <30: avoid extended interval dosing; consider conventional interval dosing
- HD: avoid extended interval dosing; consider conventional interval dosing; PD: not defined
- [cystic fibrosis, conventional interval dosing]
- CrCl 10-50: give usual dose q12-24h; CrCl <10: give usual dose x1, then redose if serum levels <1-2 mg/mL; Info: adjust dose, frequency based on serum levels
- HD: give usual dose x1, then redose after dialysis if serum levels <1-2 mg/mL; no supplement; PD: not defined; Info: adjust dose, frequency based on serum levels
- [cystic fibrosis, extended interval dosing]
- CrCl 30-60: adjust frequency based on serum levels; CrCl <30: avoid extended interval dosing; consider conventional interval dosing
- HD: avoid extended interval dosing; consider conventional interval dosing; PD: not defined
hepatic dosing
- [not defined]
Peds Dosing .
- Dosage forms: INJ
bacterial infections, neonatal dosing
- [<30 wk gestation, 0-7 days old]
- Dose: 5 mg/kg/dose IV q48h; Info: adjust dose based on serum levels
- [<30 wk gestation, 8-28 days old]
- Dose: 4 mg/kg/dose IV q36h; Info: adjust dose based on serum levels
- [<30 wk gestation, 29 days old and older]
- Dose: 4 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [30-34 wk gestation, 0-7 days old]
- Dose: 4.5 mg/kg/dose IV q36h; Info: adjust dose based on serum levels
- [30-34 wk gestation, 8 days old and older]
- Dose: 4 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [35 wk gestation and older, 0-28 days old]
- Dose: 4 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
bacterial infections, conventional interval dosing
- [1 mo and older]
- Dose: 2.5 mg/kg/dose IV q8h; Info: adjust dose based on serum levels; consider using IBW in pts 1 mo and older
bacterial infections, extended interval dosing
- [3 mo-2 yo]
- Dose: 9.5 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [2-8 yo]
- Dose: 8.5 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [8 yo and older]
- Dose: 7 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
resp. infections, cystic fibrosis pts
- [conventional interval dosing, 1 mo and older]
- Dose: 2.5-3.5 mg/kg/dose IV q8h; Info: adjust dose based on serum levels; consider using IBW in pts 1 mo and older
- [extended interval dosing, 1 mo and older]
- Dose: 10-12 mg/kg/dose IV q24h; Info: adjust dose based on serum levels; consider using IBW in pts 1 mo and older
febrile neutropenia, post-stem cell transplant (off-label)
- [<5 yo]
- Dose: 9 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [5-11 yo]
- Dose: 8 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
- [12 yo and older]
- Dose: 7 mg/kg/dose IV q24h; Info: adjust dose based on serum levels
UTI (off-label)
- [2 mo-2 yo]
- Dose: 5 mg/kg/day IV divided q8h x7-14 days; Info: duration varies w/ infection type, severity; adjust dose based on serum levels; consider using IBW
renal dosing
- [neonatal dosing]
- renal impairment: not defined; Info: adjust dose based on serum levels
- HD/PD: not defined; Info: adjust dose based on serum levels
- [non-cystic fibrosis, conventional interval dosing]
- CrCl 10-50: give usual dose q12-24h; CrCl <10: give usual dose q48-72h; Info: adjust dose based on serum levels
- HD: give usual dose x1, then adjust dose based on serum levels; no supplement; PD: not defined
- [non-cystic fibrosis, extended interval dosing]
- CrCl 30-60: adjust frequency based on serum levels; CrCl <30: avoid extended interval dosing; consider conventional interval dosing
- HD: avoid extended interval dosing; consider conventional interval dosing; PD: not defined
- [cystic fibrosis, conventional interval dosing]
- CrCl 10-50: give usual dose q12-24h; CrCl <10: give usual dose q48-72h; Info: adjust dose based on serum levels
- HD: give usual dose x1, then adjust dose based on serum levels; no supplement; PD: not defined
- [cystic fibrosis, extended interval dosing]
- CrCl 30-60: adjust frequency based on serum levels; CrCl <30: avoid extended interval dosing; consider conventional interval dosing
- HD: avoid extended interval dosing; consider conventional interval dosing; PD: not defined
hepatic dosing
- [not defined]
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- caution: hypersensitivity to sulfites (some INJ forms)
- caution: nephrotoxic agent use, concurrent
- caution: ototoxic agent use, concurrent
- caution: neurotoxic agent use, concurrent
- caution: neonates
- caution: infants
- caution: elderly pts
- caution: renal impairment
- caution: vestibular fxn, impaired
- caution: auditory fxn, impaired
- caution: neuromuscular dz
- caution: dehydration
- caution: electrolyte abnormalities
- caution: prolonged use
- caution: high-dose use
- caution: maternal ototoxicity hx, aminoglycoside-induced
- caution: hearing loss family hx
- caution: abx-associated colitis hx, recent
- caution: botulism
Drug Interactions .
Overview
tobramycin
aminoglycoside
- alters GI flora
- hypocalcemia
- hypomagnesemia
- impairs immunomodulatory bacterial infective agent
- nephrotoxicity
- neuromuscular blocking effects
- ototoxicity
Contraindicated
- cidofovir
Avoid/Use Alternative
- acyclovir
- adefovir dipivoxil
- aldesleukin
- alectinib
- amikacin
- amikacin inhaled
- amphotericin
- anthrax immune globulin
- auranofin
- avanafil
- axitinib
- balsalazide
- BCG live intravesical
- bevacizumab
- botulinum toxin
- botulism immune globulin
- bumetanide
- cabozantinib
- capecitabine
- carboplatin
- carfilzomib
- chloroquine
- cisplatin
- clindamycin
- clofarabine
- colistimethate
- creatine
- cyclophosphamide
- cyclosporine
- cytomegalovirus immune globulin
- deferasirox
- deferoxamine
- desflurane
- docetaxel
- eflornithine
- ethacrynic acid
- everolimus
- exenatide
- fecal microbiota, live
- fenoprofen
- flucytosine
- fludarabine
- foscarnet
- furosemide
- galsulfase
- ganciclovir
- gentamicin
- ifosfamide
- immune globulin
- inotersen
- iobenguane I 131
- iohexol
- isoflurane
- isotretinoin
- itraconazole
- lenvatinib
- lifileucel
- liraglutide
- lithium
- lutetium Lu 177 vipivotide tetraxetan
- mannitol
- mesalamine
- mesalamine rectal
- methotrexate
- mitomycin
- naproxen
- neomycin
- nusinersen
- olsalazine
- oxaliplatin
- pamidronate
- pancuronium
- paromomycin
- pazopanib
- pemetrexed
- penicillamine
- pentamidine
- pentostatin
- plazomicin
- polymyxin B
- quinidine (antiarrhythmic)
- quinine
- ramucirumab
- Rho(D) immune globulin
- rituximab
- rocuronium
- ropeginterferon alfa-2b
- salsalate
- sildenafil
- sirolimus
- sitagliptin
- sodium phosphate (bowel prep)
- sparsentan
- streptomycin
- streptozocin
- succinylcholine
- sunitinib
- tacrolimus
- tadalafil
- telavancin
- temsirolimus
- tenofovir alafenamide
- tenofovir disoproxil
- teprotumumab
- tiopronin
- tivozanib
- tobramycin
- tobramycin inhaled
- torsemide
- tretinoin
- vaccinia immune globulin
- valacyclovir
- valganciclovir
- vancomycin
- vardenafil
- vecuronium
- vinblastine
- vincristine
- vinorelbine
- voclosporin
- ziv-aflibercept
- zoledronic acid
Monitor/Modify Tx
- alendronate
- aliskiren
- amifostine
- amiloride
- aspirin
- atracurium
- azilsartan medoxomil
- benazepril
- bleomycin
- brexucabtagene autoleucel
- calcitonin-salmon
- candesartan cilexetil
- captopril
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- cefpodoxime proxetil
- cefprozil
- ceftazidime
- cefuroxime sodium
- celecoxib
- cetuximab
- chlorothiazide
- chlorthalidone
- cinacalcet
- cisatracurium
- denosumab
- dexlansoprazole
- diclofenac
- diclofenac topical
- diflunisal
- enalapril
- enalaprilat
- etelcalcetide
- etodolac
- flurbiprofen
- fosinopril
- hydrochlorothiazide
- ibandronate
- ibuprofen
- ibuprofen lysine
- indapamide
- indomethacin
- irbesartan
- ketoprofen
- ketorolac
- lenalidomide
- lisinopril
- losartan
- magnesium citrate
- magnesium salicylate
- meclofenamate
- mefenamic acid
- meloxicam
- metolazone
- moexipril
- nabumetone
- necitumumab
- olmesartan medoxomil
- oxaprozin
- patiromer
- perindopril
- piroxicam
- polyethylene glycol
- polyethylene glycol/electrolytes
- pralsetinib
- quinapril
- quinidine (CYP2D6 inhibitor)
- ramipril
- risedronate
- romosozumab
- sacituzumab govitecan
- sevoflurane
- spironolactone
- sulfate bowel prep
- sulindac
- telmisartan
- thalidomide
- tolmetin
- trandolapril
- triamterene
- valsartan
- vonoprazan
- warfarin
- zonisamide
Therapeutic Advantage
- amoxicillin
- ampicillin
- dicloxacillin
- nafcillin
- oxacillin
- penicillin G
- penicillin V
- piperacillin
Caution Advised
- daptomycin
- dimenhydrinate
- emtricitabine
- lactulose
- mycophenolate mofetil
- mycophenolic acid
- sodium picosulfate
Adverse Reactions .
Serious Reactions
- ototoxicity, auditory
- ototoxicity, vestibular
- nephrotoxicity
- neurotoxicity
- neuromuscular blockade
- C. difficile-assoc. diarrhea
- anaphylaxis
- hypersensitivity rxn
- exfoliative dermatitis
- toxic epidermal necrolysis
- erythema multiforme
- Stevens-Johnson syndrome
Common Reactions
- BUN or Cr elevated
- dizziness
- vertigo
- tinnitus
- hearing loss
- injection site rxn
Safety/Monitoring .
Therapeutic Drug Levels
Conventional Dosing: 6-10 mcg/mL (peak), <2 mcg/mL (trough); Adult Extended Interval: see nomogram (random), <0.5 mcg/mL (trough); Peds Extended Interval: 20-30 mcg/mL (peak), <0.5 mcg/mL (trough); Cystic Fibrosis Extended Interval: 20-40 mcg/mL (peak), <0.5 mcg/mL (trough); Toxic Levels, Conventional Dosing: >12 mcg/mL (peak); Toxic Levels, Peds Extended Interval: >30 mcg/mL (peak); Toxic Levels, Cystic Fibrosis Extended Interval: >40 mcg/mL (peak); Toxic Levels, All Indications: >1-2 mcg/mL (trough); Timing: peak 30-60min after IM/IV, trough just before next dose; Time to Steady State: 5-15h (adults), 3-12h (children), 15-25h (infants), 20-40h (neonates)
Monitoring Parameters
BUN/Cr at baseline, then periodically; serum drug levels; urinalysis; audiometry for high risk pts, planned prolonged tx, if excessive levels or s/sx hearing impairment
Look/Sound-Alike Drug Names
tobramycin confused with: gentamicin; vancomycin
Pregnancy/Lactation .
Pregnancy
Clinical Summary
weigh risk/benefit during pregnancy; no human data available, though risk of nephrotoxicity and irreversible congenital ototoxicity based on human data w/ other aminoglycosides
Lactation
Clinical Summary
may use while breastfeeding; no known risk of infant harm based on limited human data and drug properties; no human data available to assess effects on milk production
Pharmacology .
Metabolism: minimal to none; CYP450: unknown
Excretion: urine (93% unchanged); Half-life: 2h; Info: half-life varies w/ renal fxn
Subclass: Aminoglycosides
Mechanism of Action
binds to bacterial 30S ribosomal subunit, inhibiting protein synthesis
Formulary .
No Formulary Selected
Manufacturer/Pricing .
Manufacturer: generic
DEA/FDA: Rx
Approximate Retail Price
from http://www.goodrx.com/tobramycin
injectable solution:
- 40 mg/mL (10 vial, 30 mL): $100.00
injectable solution:
- 40 mg/mL (84 vial, 2 mL): $77.00
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