tobramycin (Rx)

Brand and Other Names:Nebcin injection
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 10mg/mL
  • 40mg/mL

Solution reconstituted

  • 1.2g

Bacterial Infections

3-6 mg/kg/day IV/IM divided q8hr OR  

4-7 mg/kg/dose IV/IM qDay

Renal Impairment

Clcr >60 mL/min: q8hr

Clcr 40-60 mL/min: q12hr

Clcr 20-40 mL/min: q24hr

Clcr 10-20 mL/min: q48hr

Clcr <10 mL/min: q72hr

Following dialysis in ESRD

Monitor

Peak and trough concentrations, renal and auditory function

Life-threatening infection: 8-10 mcg/mL

Serious infection: 6-8 mcg/mL

UTIs: 4-6 mcg/mL

Synergy for infections caused by gram-positive organisms: 3-5 mcg/mL

Other Indications & Uses

May have increase activity against resistant Gram negatives

Citrobacter spp., E. coli, P. aeruginosa, Proteus spp. (indole-positive and negative), Providencia spp. (including Klebsiella-Enterobacter-Serratia), S. aureus (coagulase-positive and negative)

Dosage Forms & Strengths

injectable solution

  • 10mg/mL
  • 40mg/mL

Cystic Fibrosis

IV/IM: 2.5-3.3 mg/kg q6-8hr  

Neonates

<30 week gestation

  • <28 days old: 2.5 mg/kg IV/IM qDay
  • ≥28 days old: 3 mg/kg IV/IM qDay

30-36 week gestation

  • <14 days old: 3 mg/kg IV/IM qDay
  • ≥14 days old: 5 mg/kg/day IV/IM divided q12hr

>37 week gestation

  • <7 days old: 5 mg/kg/day IV/IM divided q12hr
  • ≥7 days old: 7.5 mg/kg/day IV/IM divided q8hr

Bacterial Infection

<5 years old: 2.5 mg/kg/dose IV/IM q8hr  

≥5 years old: 2-2.5 mg/kg/dose IV/IM q8hr

Hemodialysis: 1.25-1.75 mg/kg/dose postdialysis

Monitor

Peak and trough concentrations, renal and auditory function

Life-threatening infection: 8-10 mcg/mL

Serious infection: 6-8 mcg/mL

UTIs: 4-6 mcg/mL

Synergy for infections caused by gram-positive organisms: 3-5 mcg/mL

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Interactions

Interaction Checker

and tobramycin

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            Contraindicated (0)

              Serious - Use Alternative (22)

              • amphotericin B deoxycholate

                amphotericin B deoxycholate and tobramycin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

              • atracurium

                tobramycin increases effects of atracurium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • bacitracin

                tobramycin and bacitracin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug. Avoid concurrent use of bacitracin with other nephrotoxic drugs

              • BCG vaccine live

                tobramycin decreases effects of BCG vaccine live by pharmacodynamic antagonism. Contraindicated. Wait until Abx Tx complete to administer live bacterial vaccine.

              • bumetanide

                bumetanide, tobramycin. Either increases toxicity of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. Increased risk of ototoxicity and nephrotoxicity.

              • cholera vaccine

                tobramycin, cholera vaccine. pharmacodynamic antagonism. Avoid or Use Alternate Drug. Avoid coadministration of cholera vaccine with systemic antibiotics since these agents may be active against the vaccine strain. Do not administer cholera vaccine to patients who have received oral or parenteral antibiotics within 14 days prior to vaccination.

              • cidofovir

                cidofovir and tobramycin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

              • cisatracurium

                tobramycin increases effects of cisatracurium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • ethacrynic acid

                ethacrynic acid, tobramycin. Either increases toxicity of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. Increased risk of ototoxicity and nephrotoxicity.

              • furosemide

                furosemide, tobramycin. Either increases toxicity of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. Increased risk of ototoxicity and nephrotoxicity.

              • incobotulinumtoxinA

                tobramycin increases effects of incobotulinumtoxinA by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • mannitol

                mannitol increases levels of tobramycin by unspecified interaction mechanism. Contraindicated.

              • neomycin PO

                neomycin PO and tobramycin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

              • onabotulinumtoxinA

                tobramycin increases effects of onabotulinumtoxinA by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • pancuronium

                tobramycin increases effects of pancuronium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • quinidine

                quinidine will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

              • rapacuronium

                tobramycin increases effects of rapacuronium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • rocuronium

                tobramycin increases effects of rocuronium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • succinylcholine

                tobramycin increases effects of succinylcholine by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              • torsemide

                torsemide, tobramycin. Either increases toxicity of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. Increased risk of ototoxicity and nephrotoxicity.

              • typhoid vaccine live

                tobramycin decreases effects of typhoid vaccine live by pharmacodynamic antagonism. Contraindicated. Wait until Abx Tx complete to administer live bacterial vaccine.

              • vecuronium

                tobramycin increases effects of vecuronium by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of apnea.

              Monitor Closely (66)

              • abobotulinumtoxinA

                tobramycin increases effects of abobotulinumtoxinA by pharmacodynamic synergism. Use Caution/Monitor. Aminoglycosides may enhance botulinum toxin effects. Closely monitor for increased neuromuscular blockade.

              • acyclovir

                acyclovir and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • amikacin

                amikacin and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • amiodarone

                amiodarone will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • bazedoxifene/conjugated estrogens

                tobramycin will decrease the level or effect of bazedoxifene/conjugated estrogens by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • capreomycin

                capreomycin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • carboplatin

                carboplatin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • cephaloridine

                cephaloridine and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • cisplatin

                cisplatin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • clarithromycin

                clarithromycin will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • clotrimazole

                clotrimazole will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • colistin

                colistin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • conjugated estrogens

                tobramycin will decrease the level or effect of conjugated estrogens by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • contrast media (iodinated)

                contrast media (iodinated) and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • cyclosporine

                cyclosporine and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • daptomycin

                tobramycin, daptomycin. Mechanism: unspecified interaction mechanism. Use Caution/Monitor. Tobramycin levels decrease and daptomycin levels increase when coadministered after single a dose.

              • deferasirox

                deferasirox, tobramycin. Other (see comment). Use Caution/Monitor. Comment: Acute renal failure has been reported during treatment with deferasirox. Coadministration of deferasirox with other potentially nephrotoxic drugs, including aminoglycosides, may increase the risk of this toxicity. Monitor serum creatinine and/or creatinine clearance in patients who are receiving deferasirox and nephrotoxic drugs concomitantly.

              • dichlorphenamide

                dichlorphenamide and tobramycin both decrease serum potassium. Use Caution/Monitor.

              • digoxin

                tobramycin will increase the level or effect of digoxin by altering intestinal flora. Applies only to oral form of both agents. Use Caution/Monitor.

              • dronedarone

                dronedarone will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • elvitegravir/cobicistat/emtricitabine/tenofovir DF

                tobramycin and elvitegravir/cobicistat/emtricitabine/tenofovir DF both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • erythromycin base

                erythromycin base will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin ethylsuccinate

                erythromycin ethylsuccinate will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin lactobionate

                erythromycin lactobionate will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin stearate

                erythromycin stearate will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • estradiol

                tobramycin will decrease the level or effect of estradiol by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • estrogens conjugated synthetic

                tobramycin will decrease the level or effect of estrogens conjugated synthetic by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • estropipate

                tobramycin will decrease the level or effect of estropipate by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • felodipine

                felodipine will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • fosphenytoin

                fosphenytoin will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • gentamicin

                gentamicin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • indinavir

                indinavir will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • ioversol

                ioversol and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • ketoconazole

                ketoconazole will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • loratadine

                loratadine will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • magnesium supplement

                magnesium supplement, tobramycin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Each enhance the neuromuscular blocking effect of the other; may have negative respiratory effects.

              • mestranol

                tobramycin will decrease the level or effect of mestranol by altering intestinal flora. Applies only to oral forms of hormone. Low risk of contraceptive failure. Use Caution/Monitor.

              • nefazodone

                nefazodone will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • nicardipine

                nicardipine will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • nifedipine

                nifedipine will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • nilotinib

                nilotinib will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • oxaliplatin

                oxaliplatin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • peramivir

                tobramycin increases levels of peramivir by decreasing renal clearance. Use Caution/Monitor. Caution when peramivir coadministered with nephrotoxic drugs.

              • phenobarbital

                phenobarbital will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • phenytoin

                phenytoin will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • polymyxin B

                polymyxin B and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • prabotulinumtoxinA

                tobramycin increases effects of prabotulinumtoxinA by pharmacodynamic synergism. Use Caution/Monitor. Aminoglycosides may enhance botulinum toxin effects. Closely monitor for increased neuromuscular blockade.

              • quercetin

                quercetin will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • rifampin

                rifampin will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • rimabotulinumtoxinB

                tobramycin, rimabotulinumtoxinB. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Aminoglycosides may enhance botulinum toxin effects. Closely monitor for increased neuromuscular blockade.

              • ritonavir

                ritonavir will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • sirolimus

                sirolimus will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • sodium picosulfate/magnesium oxide/anhydrous citric acid

                tobramycin decreases effects of sodium picosulfate/magnesium oxide/anhydrous citric acid by altering metabolism. Use Caution/Monitor. Coadministration with antibiotics decreases efficacy by altering colonic bacterial flora needed to convert sodium picosulfate to active drug.

              • sodium sulfate/?magnesium sulfate/potassium chloride

                sodium sulfate/?magnesium sulfate/potassium chloride increases toxicity of tobramycin by Other (see comment). Use Caution/Monitor. Comment: Coadministration with medications that cause fluid and electrolyte abnormalities may increase the risk of adverse events of seizure, arrhythmias, and renal impairment.

              • sodium sulfate/potassium sulfate/magnesium sulfate

                sodium sulfate/potassium sulfate/magnesium sulfate increases toxicity of tobramycin by Other (see comment). Use Caution/Monitor. Comment: Coadministration with medications that cause fluid and electrolyte abnormalities may increase the risk of adverse events of seizure, arrhythmias, and renal impairment.

              • St John's Wort

                St John's Wort will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • streptozocin

                streptozocin and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              • tacrolimus

                tacrolimus will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

                tacrolimus and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • teicoplanin

                teicoplanin and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

              • tenofovir DF

                tenofovir DF and tobramycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

                tobramycin increases levels of tenofovir DF by decreasing elimination. Use Caution/Monitor.

              • tolvaptan

                tolvaptan will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • trazodone

                trazodone will decrease the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • trimagnesium citrate anhydrous

                tobramycin, trimagnesium citrate anhydrous. Either increases effects of the other by Other (see comment). Use Caution/Monitor. Comment: Coadministration of aminoglycosides with magnesium may increase risk of neuromuscular weakness and paralysis.

              • verapamil

                verapamil will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • voclosporin

                voclosporin, tobramycin. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Coadministration with drugs associated with nephrotoxicity may increase the risk for acute and/or chronic nephrotoxicity.

              • warfarin

                tobramycin increases effects of warfarin by unknown mechanism. Use Caution/Monitor.

              Minor (70)

              • aceclofenac

                aceclofenac increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • acemetacin

                acemetacin increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • adefovir

                adefovir and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • aspirin

                aspirin increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • aspirin rectal

                aspirin rectal increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • aspirin/citric acid/sodium bicarbonate

                aspirin/citric acid/sodium bicarbonate increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • aztreonam

                aztreonam, tobramycin. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Combination may be used synergistically against Pseudomonas spp. and Enterobacteriaceae.

              • balsalazide

                tobramycin will decrease the level or effect of balsalazide by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • biotin

                tobramycin will decrease the level or effect of biotin by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • calcium acetate

                tobramycin decreases levels of calcium acetate by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • calcium carbonate

                tobramycin decreases levels of calcium carbonate by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • calcium chloride

                tobramycin decreases levels of calcium chloride by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • calcium citrate

                tobramycin decreases levels of calcium citrate by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • calcium gluconate

                tobramycin decreases levels of calcium gluconate by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • celecoxib

                celecoxib increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • choline magnesium trisalicylate

                choline magnesium trisalicylate increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • clotrimazole

                clotrimazole decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • cordyceps

                cordyceps decreases toxicity of tobramycin by unspecified interaction mechanism. Minor/Significance Unknown.

              • cyanocobalamin

                tobramycin decreases levels of cyanocobalamin by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • diclofenac

                diclofenac increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • diflunisal

                diflunisal increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • entecavir

                tobramycin, entecavir. Either increases effects of the other by decreasing renal clearance. Minor/Significance Unknown. Coadministration with drugs that reduce renal function or compete for active tubular secretion may increase serum concentrations of either entecavir or the coadministered drug.

              • etodolac

                etodolac increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • fenoprofen

                fenoprofen increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • fluconazole

                fluconazole decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • flurbiprofen

                flurbiprofen increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • foscarnet

                foscarnet and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • ibuprofen

                ibuprofen increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • ibuprofen IV

                ibuprofen IV increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • indomethacin

                indomethacin increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • ketoconazole

                ketoconazole decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • ketoprofen

                ketoprofen increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • ketorolac

                ketorolac increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • ketorolac intranasal

                ketorolac intranasal increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • lornoxicam

                lornoxicam increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • magnesium chloride

                tobramycin decreases levels of magnesium chloride by increasing renal clearance. Minor/Significance Unknown.

              • magnesium citrate

                tobramycin decreases levels of magnesium citrate by increasing renal clearance. Minor/Significance Unknown.

              • magnesium hydroxide

                tobramycin decreases levels of magnesium hydroxide by increasing renal clearance. Minor/Significance Unknown.

              • magnesium oxide

                tobramycin decreases levels of magnesium oxide by increasing renal clearance. Minor/Significance Unknown.

              • magnesium sulfate

                tobramycin decreases levels of magnesium sulfate by increasing renal clearance. Minor/Significance Unknown.

              • meclizine

                meclizine, tobramycin. Mechanism: unspecified interaction mechanism. Minor/Significance Unknown. Ototoxicity of aminoglycoside may be masked.

              • meclofenamate

                meclofenamate increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • mefenamic acid

                mefenamic acid increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • meloxicam

                meloxicam increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • methoxyflurane

                methoxyflurane and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • miconazole vaginal

                miconazole vaginal decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • nabumetone

                nabumetone increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • naproxen

                naproxen increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • oxaprozin

                oxaprozin increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • pantothenic acid

                tobramycin will decrease the level or effect of pantothenic acid by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • parecoxib

                parecoxib increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • paromomycin

                paromomycin and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • pentamidine

                pentamidine and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • piperacillin

                piperacillin increases effects of tobramycin by pharmacodynamic synergism. Minor/Significance Unknown.

              • piroxicam

                piroxicam increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • posaconazole

                posaconazole decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • pyridoxine

                tobramycin will decrease the level or effect of pyridoxine by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • pyridoxine (Antidote)

                tobramycin will decrease the level or effect of pyridoxine (Antidote) by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • salicylates (non-asa)

                salicylates (non-asa) increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • salsalate

                salsalate increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • streptomycin

                streptomycin and tobramycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • sulfasalazine

                sulfasalazine increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • sulindac

                sulindac increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • thiamine

                tobramycin will decrease the level or effect of thiamine by altering intestinal flora. Applies only to oral form of both agents. Minor/Significance Unknown.

              • ticarcillin

                ticarcillin decreases effects of tobramycin by altering metabolism. Minor/Significance Unknown. Increased risk in renal impairment.

              • tolfenamic acid

                tolfenamic acid increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • tolmetin

                tolmetin increases levels of tobramycin by decreasing renal clearance. Minor/Significance Unknown. Interaction mainly occurs in preterm infants.

              • vancomycin

                tobramycin and vancomycin both increase nephrotoxicity and/or ototoxicity. Minor/Significance Unknown.

              • voriconazole

                voriconazole decreases levels of tobramycin by unknown mechanism. Minor/Significance Unknown.

              • zoledronic acid

                tobramycin, zoledronic acid. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive hypocalcemia.

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              Adverse Effects

              1-10%

              Ototoxicity

              Nephrotoxicity

              Neurotoxicity (neuromuscular blockade)

              <1%

              Hypotension

              Drug fever

              Drowsiness

              Headache

              Paresthesia

              Tremor

              Rash

              Nausea

              Vomiting

              Anemia

              Eosinophilia

              Arthralgia

              Weakness

              Eyelid edema

              Itching eyes

              Keratitis

              Lacrimation

              Dyspnea

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              Warnings

              Black Box Warnings

              Neurotoxicity, manifested as both bilateral auditory and vestibular ototoxicity, can occur in patients with preexisting renal damage and in patients with normal renal function treated at higher doses and/or for periods longer than those recommended; high-frequency deafness usually occurs first and can be detected only by audiometric testing; vertigo may occur and may be evidence of vestibular injury

              Patients who develop cochlear damage may not have symptoms during therapy to warn them of eighth-nerve toxicity, and partial or total irreversible bilateral deafness may continue to develop after the drug has been discontinued

              When feasible, recommended that serial audiograms be obtained in patients old enough to be tested, particularly high-risk patients; evidence of impairment of renal, vestibular, or auditory function requires discontinuation of drug or dosage adjustment

              Aminoglycosides are potentially nephrotoxic; risk is greater in patients with impaired renal function and in those who receive high doses or prolonged therapy; rarely, nephrotoxicity may not become apparent until the first few days after cessation of therapy

              Use with caution in premature infants and neonates because of renal immaturity and the resulting prolongation of serum half-life of the drug

              Neuromuscular blockade and respiratory paralysis have been reported following parenteral injection, topical instillation (as in orthopedic and abdominal irrigation or in local treatment of empyema), and oral use of aminoglycosides, especially when given soon after anesthesia or muscle relaxants; if blockage occurs, calcium salts may reverse these phenomena, but mechanical respiratory assistance may be necessary

              Avoid concurrent or sequential use of neurotoxic and/or nephrotoxic drugs including other aminoglycosides (eg, amikacin, streptomycin, neomycin, kanamycin, gentamicin, paromomycin

              Cumulative listing of drugs to avoid from all aminoglycoside package inserts includes amphotericin B, bacitracin, cephaloridine, cisplatin, colistin, polymyxin B, vancomycin, and viomycin. Avoid potent diuretics (eg, ethacrynic acid, furosemide) because they increase risk of ototoxicity. When administered intravenously, diuretics may enhance aminoglycoside toxicity by altering antibiotic concentrations in serum and tissue

              Contraindications

              Documented hypersensitivity to any aminoglycoside or history of hypersensitivity or serious toxic reactions to aminoglycosides

              Cautions

              Serious allergic sometimes fatal reactions including anaphylaxis and dermatologic reactions including exfoliative dermatitis, toxic epidermal necrolysis, erythema multiforme, and Stevens-Johnson Syndrome reported rarely; discontinue therapy If allergic reaction occurs, drug should be discontinued and appropriate therapy instituted

              Serum and urine specimens for examination should be collected during therapy; serum calcium, magnesium, and sodium should be monitored

              Cross-allergenicity among aminoglycosides has been demonstrated

              In patients with extensive burns or cystic fibrosis, altered pharmacokinetics may result in reduced serum concentrations of aminoglycosides; in such patients treated with tobramycin, measurement of serum concentration is especially important as a basis for determination of appropriate dosage

              Elderly patients may have reduced renal function that may not be evident in results of routine screening tests, such as BUN or serum creatinine; a creatinine clearance determination may be more useful; monitoring of renal function during treatment with aminoglycosides is particularly important in such patients

              An increased incidence of nephrotoxicity reported following concomitant administration of aminoglycoside antibiotics and cephalosporins

              Aminoglycosides should be used with caution in patients with muscular disorders, such as myasthenia gravis or parkinsonism, since these drugs may aggravate muscle weakness because of potential curare-like effect on neuromuscular function

              Aminoglycosides may be absorbed in significant quantities from body surfaces after local irrigation or application and may cause neurotoxicity and nephrotoxicity

              Aminoglycosides have not been approved for intraocular and/or subconjunctival use; physicians are advised that macular necrosis has been reported following administration of aminoglycosides, including tobramycin, by these routes

              The inactivation of tobramycin and other aminoglycosides by ß-lactam-type antibiotics (penicillins or cephalosporins) has been demonstrated in vitro and in

              patients with severe renal impairment; such inactivation has not been found in patients with normal renal function who have been given the drugs by separate routes of administration

              Therapy with tobramycin may result in overgrowth of nonsusceptible organisms; if overgrowth of nonsusceptible organisms occurs, appropriate therapy should be initiated

              Clostridium difficile

              • Clostridium difficile associated diarrhea (CDAD) reported; may range
              • in severity from mild diarrhea to fatal colitis; treatment with antibacterial agents alters normal flora of colon leading to overgrowth of C. difficile
              • C. difficile produces toxins A and B which contribute to development of CDAD; hypertoxin producing strains of C. difficile cause increased morbidity and mortality
              • As these infections can be refractory to antimicrobial therapy and may require colectomy; CDAD must be considered in all patients who present with diarrhea following antibiotic use
              • Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents
              • If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued
              • Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated

              Peak and trough levels

              • Peak and trough serum levels should be measured periodically during therapy; prolonged concentrations above 12 mcg/mL should be avoided
              • Rising trough levels (above 2 mcg/mL) may indicate tissue accumulation; such accumulation, advanced age, and cumulative dosage may contribute to ototoxicity and nephrotoxicity; it is particularly important to monitor serum levels closely in patients with known renal impairment.
              • A useful guideline would be to perform serum level assays after 2 or 3 doses, so that dosage could be adjusted if necessary, and at 3- to 4-day intervals during therapy
              • In the event of changing renal function, more frequent serum levels should be obtained and the dosage or dosage interval adjusted according to guidelines
              • In order to measure the peak level, a serum sample should be drawn about 30 minutes following intravenous infusion or 1 hour after an intramuscular injection
              • Trough levels are measured by obtaining serum samples at 8 hours or just prior to next dose; these suggested time intervals are intended only as guidelines and may vary according to institutional practices
              • It is important, that there be consistency within individual patient program unless computerized pharmacokinetic dosing programs are available in the institution
              • Serum-level assays may be especially useful for monitoring treatment of severely ill patients with changing renal function or of those infected with less susceptible organisms or those receiving maximum dosage

              Neuromuscular blockade

              • Neuromuscular blockade and respiratory paralysis have been reported in cats receiving very high doses of tobramycin (40 mg/kg)
              • Possibility of prolonged or secondary apnea should be considered if tobramycin is administered to anesthetized patients who are also receiving neuromuscular blocking agents, such as succinylcholine, tubocurarine, or decamethonium, or to patients receiving massive transfusions of citrated blood
              • If neuromuscular blockade occurs, may be reversed by administration of calcium salts
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              Pregnancy & Lactation

              Pregnancy

              Therapy, can cause fetal harm when administered to a pregnant woman; published literature reports that use of streptomycin, an aminoglycoside, can cause total, irreversible, bilateral congenital deafness when administered to a pregnant woman

              Animal data

              • In animal reproduction studies with subcutaneous administration of tobramycin in pregnant rats and rabbits during organogenesis, there were no adverse developmental outcomes at doses up to 3.2 times and 1.3 times maximum recommended clinical dose based on body surface area; however, ototoxicity was not evaluated in offspring from these studies; advise pregnant women of potential risk to a fetus

              Lactation

              Limited published data with tobramycin for injection in lactating women indicate that tobramycin is present in human milk; there are no data on effects of drug on milk production; drug may cause alteration in the intestinal flora of breastfeeding infant; advise a woman to monitor breastfed infant for loose or bloody stools and candidiasis (thrush, diaper rash).

              Developmental and health benefits of breastfeeding should be considered along with mother's clinical need for therapy and any potential adverse effects on breastfed infant from drug or from underlying maternal condition

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Inhibits protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes

              Absorption

              Absorption: IM: rapid and complete

              Peak Plasma Time: IM: 30-60 min; IV: ~30 min

              Distribution

              Distribution: to extracellular fluid including serum, abscesses, ascitic, pericardial, pleural, synovial, lymphatic, and peritoneal fluids; crosses placenta; poor penetration into CSF, eye, bone, prostate

              Protein Bound: <30%

              Vd: 0.2-0.3 L/kg; pediatrics: 0.2-0.7 L/kg

              Elimination

              Half-Life: 2-3 hr (normal renal function)

              Excretion: ~90%-95% in urine within 24 hr (normal renal function)

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              Administration

              IV Incompatibilities

              Additive: cefamandole, cefepime, cefotaxime, cefotetan, floxacillin, heparin, penicillins

              Syringe: cefamandole, clindamycin, heparin

              Y-site: allopurinol, amphotericin B cholesteryl sulfate, cefoperazone, heparin, hetastarch, indomethacin, propofol, sargramostim

              IV Preparation

              Standard diluent: 50-100 mL of D5W or NS

              IV Administration

              Infuse over 30-60 min

              Give penicillins or cephalosporins at least 1 hr apart from tobramycin

              Storage

              Stable at room temp both as the clear, colorless solution & as the dry powder

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              Images

              No images available for this drug.
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              Patient Handout

              A Patient Handout is not currently available for this monograph.
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              Formulary

              FormularyPatient Discounts

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              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
              Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
              QL Quantity Limits
              Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
              ST Step Therapy
              Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
              OR Other Restrictions
              Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.