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Pharmacologic class: Aminoglycoside
Therapeutic class: Anti-infective
Pregnancy risk category B (inhalation, ophthalmic), D (parenteral)
Pregnancy risk category B (inhalation, ophthalmic), D (parenteral)
FDA Box Warning
The following boxed warnings apply to parenteral administration only:
When giving drug by injection, observe patient closely for potential ototoxicity and nephrotoxicity. Rarely, nephrotoxicity doesn't emerge until first few days after therapy ends.
Neurotoxicity, manifested as both auditory and vestibular ototoxicity, can occur. Auditory changes are irreversible and usually bilateral. Eighth-nerve impairment and nephrotoxicity also may develop, mainly in patients with preexisting renal damage and in those with normal renal function who receive drug for longer periods or in higher doses than those recommended. Other neurotoxicity manifestations may include numbness, skin tingling, muscle twitching, and seizures. Risk of drug-induced hearing loss increases with degree of exposure to high peak or high trough drug blood levels. Patients who develop cochlear damage may lack symptoms during therapy to warn of eighth-nerve toxicity, and partial or total irreversible bilateral deafness may continue to develop after withdrawal.
Monitor renal and eighth-nerve function closely in patients with known or suspected renal impairment and in those whose renal functional initially is normal but who develop signs of renal dysfunction during therapy. Monitor peak and trough drug blood levels periodically during therapy; avoid levels above 12 mcg. Rising trough levels (above 2 mcg) may indicate tissue accumulation. Such accumulation, excessive peak levels, advanced age, and cumulative dose may contribute to ototoxicity and nephrotoxicity. Examine urine for decreased specific gravity and increased protein, cells, and casts. Measure blood urea nitrogen (BUN), serum creatinine, and creatinine clearance periodically. When feasible, obtain serial audiograms. Evidence of impairment of renal, vestibular, or auditory function warrants drug withdrawal or dosage adjustment.
Avoid concurrent or sequential use of other neurotoxic or nephrotoxic antibiotics, especially other aminoglycosides (such as amikacin, gentamicin, kanamycin, neomycin, and streptomycin), cephaloridine, cisplatin, colistin, polymyxin B, vancomycin, and viomycin. Advanced age and dehydration also increase risk.
Don't give concurrently with potent diuretics (such as furosemide and ethacrynic acid), because these drugs are also ototoxic. Also, I.V. diuretics may increase tobramycin toxicity by altering antibiotic serum and tissue levels.
Use drug cautiously in premature infants and neonates.
Drug may harm fetus when given to pregnant women.
Interferes with protein synthesis in bacterial cell by binding to 30S ribosomal subunit
Injection: 10 mg/ml, 40 mg/ml, 1.2-g vial
Nebulizer solution: 300 mg/5 ml in 5-ml ampule
Ophthalmic ointment: 0.3%
Ophthalmic solution: 0.3%
Pediatric solution for injection: 20 mg/2 ml
Premixed I.V. solution: 60 mg in 50 ml normal saline, 80 mg in 100 ml normal saline
⊘Indications and dosages
➣ Serious infections caused by susceptible organisms
Adults: 3 mg/kg/day I.V. or I.M. in evenly divided doses q 8 hours. For life-threatening infections, may increase up to 5 mg/kg/day I.V. or I.M. in three or four evenly divided doses, then reduce to 3 mg/kg/day as soon as possible.
Children older than 1 week: 6 to 7.5 mg/kg/day in three or four evenly divided doses, such as 2 to 2.5 mg/kg I.V. or I.M. q 8 hours or 1.5 to 1.9 mg/kg I.V. or I.M. q 6 hours
Neonates less than 1 week old: Up to 4 mg/kg/day I.V. or I.M. in evenly divided doses q 12 hours
➣Pseudomonas aeruginosa in cystic fibrosis patients
Adults and children older than age 6: 300 mg inhalation b.i.d. (preferably q 12 hours but no less than 6 hours apart) for 28 days, then off for 28 days; then repeat cycle
➣ Ocular infections caused by susceptible organisms
Adults and children: For mild to moderate infections, apply a ribbon of ophthalmic ointment (approximately 1 cm) to infected eye two or three times daily, or instill one to two drops of ophthalmic solution into infected eye q 4 hours. For severe infections, apply ophthalmic ointment q 3 to 4 hours or instill two drops of ophthalmic solution into infected eye q 30 to 60 minutes; decrease dosing frequency when improvement occurs. Therapy should continue for at least 48 hours after infection is under control.
• Renal impairment
• Hypersensitivity to drug, other aminoglycosides, bisulfites (with some products), or benzyl alcohol (in neonates, with some products)
Use cautiously in:
• renal or hearing impairment, neuromuscular diseases, obesity
• elderly patients
• pregnant or breastfeeding patients
• neonates and premature infants.
• Know that premixed I.V. solution is ready to use and requires no further dilution. Don't mix with other drugs.
Don't use flexible container in series connections because of risk of air embolism.
• Dilute I.V. dose from vials in 50 to 100 ml of normal saline solution or dextrose 5% in water. For child, smaller volumes are needed.
• Infuse over at least 30 minutes. Flush line after administration.
• Give cephalosporins or penicillin, if ordered, 1 hour before or after tobramycin.
• Give inhalation doses by nebulizer over 10 to 15 minutes.
CNS: confusion, lethargy, headache, delirium, dizziness, vertigo
EENT: eye stinging (with ophthalmic form), ototoxicity, hearing loss, roaring in ears, tinnitus
GI: nausea, vomiting, diarrhea, stomatitis
GU: proteinuria, oliguria, nephrotoxicity
Hematologic: anemia, eosinophilia, leukocytosis, leukopenia, thrombocytopenia, granulocytopenia
Metabolic: hypocalcemia, hyponatremia, hypokalemia, hypomagnesemia
Musculoskeletal: muscle weakness
Skin: rash, urticaria, itching
Other: superinfection, fever, pain and irritation at injection site
Drug-drug. Cephalosporins, vancomycin: increased risk of nephrotoxicity
Dimenhydrinate: masking of ototoxicity symptoms
General anesthetics, neuromuscular blockers: increased neuromuscular blockade and respiratory depression
Indomethacin: increased tobramycin trough and peak levels
Loop diuretics: increased risk of ototoxicity
Penicillins: physical incompatibility, tobramycin inactivation when mixed in same I.V. solution
Polypeptide anti-infectives: increased risk of respiratory paralysis and renal dysfunction
Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase, bilirubin, BUN, creatinine, lactate dehydrogenase, nonprotein nitrogen, urine protein: increased levels
Calcium, granulocytes, hemoglobin, magnesium, platelets, potassium, sodium, white blood cells: decreased levels
• Draw sample for peak drug level 1 hour after I.M. or 30 minutes after I.V. administration. Draw sample for trough level just before next dose.
• Assess liver and kidney function tests.
• Monitor CBC with white cell differential.
• Closely monitor patient's hearing.
Tell patient drug may cause hearing impairment and other serious adverse reactions, such as unusual bleeding or bruising. Instruct him to report these reactions at once.
• Advise patient to report new signs or symptoms of infection.
• With inhalation form, teach patient how to use nebulizer. Instruct him to administer dose over 10 to 15 minutes by breathing normally through mouthpiece while sitting or standing. Remind him to use only the hand-held nebulizer and compressor originally dispensed with drug. Advise him to use a nose clip to help him breathe through his mouth. If he uses other inhaled drugs, instruct him to take tobramycin last.
• Teach patient proper use of eye drops. Caution him not to touch dropper to eye or any other surface.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.