Micromedex Care Notes:
Medical Encyclopedia:
Generic Name: atropine and diphenoxylate (A troe peen and DYE fen OX i late)
Brand Names: Lomotil, Lonox, Vi-Atro
Atropine affects the body in many different ways, such as reducing spasms in the bladder, stomach, and intestines.
Diphenoxylate is an antidiarrheal medication.
The combination of atropine and diphenoxylate is used to treat diarrhea.
Atropine and diphenoxylate may also be used for other purposes not listed in this medication guide.
Use only the liquid form of this medicine in a child younger than 13 years old. Do not give atropine and diphenoxylate tablets to a child under 13.
jaundice (yellowing of your skin or eyes caused by a liver disorder);
diarrhea that is caused by bacteria; or
diarrhea caused by taking an antibiotic.
Before taking atropine and diphenoxylate, tell your doctor if you are allergic to any drugs, or if you have:
blocked intestines;
an intestinal disorder such as ulcerative colitis or Crohn's disease;
heart disease, heart rhythm problems, or high blood pressure;
glaucoma;
Down's syndrome;
a thyroid disorder;
problems with urination;
an enlarged prostate;
asthma or other lung problems; or
if you are dehydrated;
If you have any of these conditions, you may need a dose adjustment or special tests to safely take atropine and diphenoxylate.
Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.
Use only the liquid form of this medicine in a child younger than 13 years old. Do not give atropine and diphenoxylate tablets to a child under 13.
Measure liquid medicine with a special dose-measuring spoon or cup, not a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one.
Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at your next regularly scheduled time. Do not take extra medicine to make up the missed dose.
Early overdose symptoms may include dry skin, dry mouth or nose, blurred vision, restless feeling, feeling too warm or cold, tingly feeling, and a fast heart rate.
Progressing symptoms of an atropine and diphenoxylate overdose include weakness, pinpoint pupils in the eyes, weak or shallow breathing, fainting, or coma. Report any early overdose symptoms to your doctor as soon as possible.
Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression or anxiety can add to sleepiness caused by atropine and diphenoxylate. Tell your doctor if you regularly use any of these other medicines.
Avoid becoming overheated or dehydrated during exercise and in hot weather. Follow your doctor's instructions about the type and amount of liquids you should drink.
stomach pain or bloating;
ongoing or worsening diarrhea;
diarrhea that is watery or bloody;
numbness in your hands or feet;
depressed mood;
confusion, unusual thoughts or behavior;
fast heart rate; or
urinating less than usual or not at all.
Less serious side effects may include:
drowsiness, dizziness, headache;
tired or restless feeling;
nausea, vomiting, upset stomach, loss of appetite; or
skin rash, or itching.
This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088.
Before taking atropine and diphenoxylate, tell your doctor if you are using any of the following drugs:
a barbiturate such as amobarbital (Amytal), butabarbital (Butisol), mephobarbital (Mebaral), secobarbital (Seconal), or phenobarbital (Luminal, Solfoton); or
an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate).
This list is not complete and there may be other drugs that can interact with atropine and diphenoxylate. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.
See also: Lonox side effects (in more detail)
CSL Behring
Streptase Injection 1,500,000 (1.5 M) I.U.
(Streptokinase)
Streptase Injection is a type of medicine called a fibrinolytic agent. It contains a substance called streptokinase, which helps to dissolve blood clots.
Streptase Injection 1.5 M IU strength is used to limit the extent of a heart attack, within 12 hours of the event occurring.
Your doctor should consider the above points before you are given Streptase Injection.
If you are taking or have recently been taking drugs which prevent blood clotting (anticoagulants), there will be an increased risk of bleeding (haemorrhage).
You should not be given Streptase Injection if you are pregnant or have recently had a baby, miscarriage or abortion, unless there is no safer alternative.
Breast milk should be discarded if you have received Streptase Injection within the last 24 hours.
Your doctor may recommend that you also take a low dose of aspirin for about 4 weeks to help thin your blood.
If you are given too much Streptase Injection over a long period, you may be at risk of another thrombosis (blood clot). Symptoms of a thrombosis are listed in the side effects section below.
Like all medicines, Streptase Injection can have side-effects, although not everybody gets them.
The following events have been reported in patients being treated with Streptase Injection, but may not have been due to the medicine:irregular heart-beat, chest pain, lack of oxygen to the heart, heart failure, heart attack, heart shock, inflammation around the heart, fluid around the heart, stopping of heart-beat, heart valve inefficiency, blockage of a blood vessel.
If you receive a lot of Streptase, you may be at risk of a thrombosis (blood clot).
If you have any of the side-effects listed in this section, or any other unusual or unexpected side-effects, tell your doctor or nurse immediately.
You will not normally be asked to store your medicine as it will be given to you by a doctor.
Keep out of the reach and sight of children.
Do not store above 25 °C. Do not freeze.
After the injection has been prepared it may be kept in a fridge at 2 to 8 ºC for up to 24 hours.
Do not use this medicine after the expiry date shown on the carton and vial label.
The active substance is:
Other ingredients are:
Streptase Injection comes as a powder in glass containers, and will be mixed with a liquid to make a solution before use as an infusion.
Each pack contains one vial with 1.5 million IU streptokinase.
This leaflet was last approved on: 04/2008
For further information contact
This leaflet was last approved on: 05/2009
A drug may be classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition. Each drug can be classified into one or more drug classes.
Antineoplastic interferons are interferons (alpha) that are manufactured using recombinant DNA technology and used therapeutically to treat certain types of cancers and viral infections.
Natural interferons enhance the immune system in many ways so can be used to treat different conditions involving the immune system. Interferons are proteins produced by host cells that are infected with viruses, bacteria, other unknown nucleic acids or tumor cells. Interferons also activate other cells that serve as part of the immune system, and destroy invading pathogens.
Antineoplastic interferons are used as part of the treatment for cancers like angioblastoma, chronic myelogenous leukemia and hairy cell leukemia, certain types of lymphomas, AIDS-related Kaposi sarcoma and malignant melanomas. They are also used in the treatment of viral infections such as hepatitis B and C, and human papillomavirus.
Medical conditions associated with antineoplastic interferons:
Rx Only
FOR DERMATOLOGICAL USE ONLY. NOT FOR OPHTHALMIC, ORAL OR INTRAVAGINAL USE.
Salicylic Acid 6% w/w Shampoo contains 6% w/w salicylic acid USP in a vehicle consisting of purified water, acrylates copolymer, sodium laureth sulfate, trolamine, lecithin in propylene glycol, cocamidopropyl betaine, propylparaben, methylparaben, glycerin, edetate disodium and chamomile tea fragrance.
Salicylic acid is the 2-hydroxy derivative of benzoic acid having the following structure:
Salicylic acid has been shown to produce desquamation of the horny layer of skin while not effecting qualitative or quantitative changes in the structure of the viable epidermis. The mechanism of action has been attributed to a dissolution of intercellular cement substance.
In a study of the percutaneous absorption of salicylic acid in a 6% salicylic acid gel in four patients with extensive active psoriasis, Taylor and Halprin showed that the peak serum salicylate levels never exceeded 5 mg/100 mL even though more than 60% of the applied salicylic acid was absorbed. Systemic toxic reactions are usually associated with much higher serum levels (30 to 40 mg/100 mL).
Peak serum levels occurred within five hours of the topical application under occlusion. The sites were occluded for 10 hours over the entire body surface below the neck. Since salicylates are distributed in the extracellular space, patients with a contracted extracellular space due to dehydration or diuretics have higher salicylate levels than those with a normal extracellular space. (See PRECAUTIONS)
The major metabolites identified in the urine after topical administration are salicyluric acid (52%), salicylate glucuronides (42%) and free salicylic acid (6%). The urinary metabolites after percutaneous absorption differ from those after oral salicylate administration; those derived from percutaneous absorption contain more salicylate glucuronides and less salicyluric and salicylic acid. Almost 95% of a single dose of salicylate is excreted within 24 hours of its entrance into the extracellular space.
Fifty to eighty percent of salicylate is protein bound to albumin. Salicylates compete with the binding of several drugs and can modify the action of these drugs; by similar competitive mechanisms other drugs can influence the serum levels of salicylate. (See PRECAUTIONS)
For Dermatologic Use: Salicylic Acid 6% w/w Shampoo is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders, including verrucae, and the various ichthyoses (vulgaris, sex-linked and lamellar), keratosis palmaris and plantaris, keratosis pilaris, pityriasis rubra pilaris, and psoriasis (including body, scalp, palms and soles).
For Podiatric Use: Salicylic Acid 6% w/w Shampoo is a topical aid in the removal of excessive keratin on dorsal and plantar hyperkeratotic lesions. Topical preparations of 6% salicylic acid have been reported to be useful adjunctive therapy for verrucae plantares.
Salicylic Acid 6% w/w Shampoo should not be used in any patient known to be sensitive to salicylic acid or any other listed ingredients. Salicylic Acid 6% w/w Shampoo should not be used in children under 2 years of age.
Prolonged use over large areas, especially in children and those patients with significant renal or hepatic impairment could result in salicylism. Excessive application of the product other than is needed to cover the affected area will not result in a more therapeutic benefit. Concomitant use of other drugs which may contribute to elevated serum salicylate levels should be avoided where the potential for toxicity is present. In children under 12 years of age and those patients with renal or hepatic impairment, the area to be treated should be limited and the patient monitored closely for signs of salicylate toxicity: nausea, vomiting, dizziness, loss of hearing, tinnitus, lethargy, hyperpnea, diarrhea, and psychic disturbances. In the event of salicylic acid toxicity, the use of Salicylic Acid 6% w/w should be discontinued. Fluids should be administered to promote urinary excretion. Treatment with sodium bicarbonate (oral or intravenous) should be instituted as appropriate. Patients should be cautioned against the use of oral aspirin and other salicylate containing medications, such as sports injury creams, to avoid additional excessive exposure to salicylic acid. Where needed, aspirin should be replaced by an alternative non-steroidal, anti-inflammatory agent that is not salicylate based.
Due to potential risk of developing Reye’s syndrome, salicylate products should not be used in children and teenagers with varicella or influenza, unless directed by a physician.
For external use only. Avoid contact with eyes and other mucous membranes.
The following interactions are from a published review and include reports concerning both oral and topical salicylate administration. The relationship of these interactions to the use of Salicylic Acid 6% w/w Shampoo is not known.
I. Due to the competition of salicylate with other drugs for binding to serum albumin the following drug interactions may occur:
| DRUG | DESCRIPTION OF INTERACTION |
| Sulfonylureas | Hypoglycemia potentiated. |
| Methotrexate | Decreases tubular reabsorption; clinical toxicity from methotrexate can result. |
| Oral Anticoagulants | Increased bleeding. |
II. Drugs changing salicylate levels by altering renal tubular reabsorption:
| DRUG | DESCRIPTION OF INTERACTION |
| Corticosteroids | Decreases plasma salicylate level; tapering doses of steroids may promote salicylism. |
| Acidifying Agents | Increases plasma salicylate level. |
| Alkanizing Agents | Decreased plasma salicylate levels. |
III. Drugs with complicated interactions with salicylates:
| DRUG | DESCRIPTION OF INTERACTION |
| Heparin | Salicylate decreases platelet adhesiveness and interferes with hemostasis in heparin treated patients. |
| Pyrazinamide | Inhibits pyrazinamide-induced hyperuricemia. |
| Uricosuric Agents | Effect of probenemide, sulfinpyrazone and phenylbutazone inhibited. |
The following alterations of laboratory tests have been reported during salicylate therapy:
| LABORATORY TESTS | EFFECT OF SALICYLATES |
| Thyroid Function | Decreased PBI; increased T3 Function uptake. |
| Urinary Sugar | False negative with glucose oxidase; false positive with Clinitest with high-dose salicylate therapy (2-5g q.d.). |
| 5-Hydroxyindole acetic acid | False negative with fluorometric test. |
| Acetone, ketone bodies | False positive FeCl3 in Gerhardt reaction; red color persists with boiling. |
| 17-OH corticosteroids | False reduced values with >4.8g q.d. salicylate. |
| Vanilmandelic acid | False reduced values. |
| Uric acid | May increase or decrease depending on dose. |
| Prothrombin | Decreased levels; slightly increased prothrombin time. |
(Category C): Salicylic acid has been shown to be teratogenic in rats and monkeys. It is difficult to extrapolate from oral doses of acetylsalicylic acid used in these studies to topical administration as the oral dose to monkeys may represent six times the maximal daily human dose of salicylic acid when applied topically over a large body surface. There are no adequate and well-controlled studies in pregnant women. Salicylic Acid 6% w/w Shampoo should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Because of the potential for serious adverse reactions in nursing infants from the mother’s use of Salicylic Acid 6% w/w Shampoo, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. If used by nursing mothers, it should not be used on the chest area to avoid the accidental contamination of the child.
No data are available concerning potential carcinogenic or reproductive effects of Salicylic Acid 6% w/w Shampoo. Salicylic acid has been shown to lack mutagenic potential in the Ames Salmonella test.
Excessive erythema and scaling conceivably could result from use on open skin lesions.
To report SUSPECTED ADVERSE REACTIONS, contact Hi-Tech Pharmacal Co., Inc. at 1-800-262-9010.
See Warnings.
Wet hair and apply Salicylic Acid 6% w/w Shampoo to the scalp. Work into a lather then rinse. Repeat the treatment as needed until the condition clears. Once clearing is apparent, the occasional use of Salicylic Acid 6% w/w Shampoo will usually maintain the remission.
Salicylic Acid 6% w/w Shampoo is available in 177 mL plastic bottles.
Store at controlled room temperature 20°-25°C (68°- 77°F). Do not freeze.
Manufactured by:
Hi-Tech Pharmacal Co., Inc.
Amityville, NY 11701
Rev. 708:00 8/09
NDC 50383-708-06
Salicylic Acid 6% w/w Shampoo
Rx Only
177 mL
Ingredients: Contains 6% w/w salicylic acid USP in a vehicle consisting of purified water, acrylates copolymer, sodium laureth sulfate, trolamine, lecithin in propylene glycol, cocamidopropyl betaine, propylparaben, methylparaben, glycerin, edetate disodium and chamomile tea fragrance.
Directions: Wet hair and apply Salicylic Acid 6% w/w Shampoo to the scalp. Work into a lather then rinse. Repeat the treatment as needed until the condition clears. Once clearing is apparent, the occasional use of Salicylic Acid 6% w/w Shampoo will usually maintain the remission.
Storage: Store at controlled room temperature 20°-25°C (68°-77°F). Do not freeze.
WARNING: FOR DERMATOLOGICAL USE ONLY. NOT FOR OPHTHALMIC, ORAL OR INTRAVAGINAL USE.
Manufactured by:
HI-TECH PHARMACAL CO., INC.
AMITYVILLE, N.Y. 11701
| SALICYLIC ACID salicylic acid shampoo | ||||||||||||||||||||||||||||
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| Marketing Information | |||
| Marketing Category | Application Number or Monograph Citation | Marketing Start Date | Marketing End Date |
| Unapproved drug other | 08/01/2008 | 11/03/2011 | |
| Labeler - Hi-Tech Pharmacal Co., Inc. (101196749) |
60 mg Tobramycin in 50 mL
80 mg Tobramycin in 50 mL or 100 mL
FOR INTRAVENOUS INFUSION ONLY
Flexible Container
Rx only
To reduce the development of drug-resistant bacteria and maintain the effectiveness of tobramycin and other antibacterial drugs, tobramycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
WARNINGS
Patients treated with Tobramycin Injection and other aminoglycosides should be under close clinical observation, because these drugs have an inherent potential for causing ototoxicity and nephrotoxicity.
Neurotoxicity, manifested as both auditory and vestibular ototoxicity, can occur. The auditory changes are irreversible, are usually bilateral, and may be partial or total. Eighth-nerve impairment and nephrotoxicity may develop, primarily in patients having pre-existing renal damage and in those with normal renal function to whom aminoglycosides are administered for longer periods or in higher doses than those recommended. Other manifestations of neurotoxicity may include numbness, skin tingling, muscle twitching, and convulsions. The risk of aminoglycoside-induced hearing loss increases with the degree of exposure to either high peak or high trough serum concentrations. 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. Rarely, nephrotoxicity may not become apparent until the first few days after cessation of therapy. Aminoglycoside-induced nephrotoxicity usually is reversible.
Renal and eighth-nerve function should be closely monitored in patients with known or suspected renal impairment and also in those whose renal function is initially normal but who develop signs of renal dysfunction during therapy. Peak and trough serum concentrations of aminoglycosides should be monitored periodically during therapy to assure adequate levels and to avoid potentially toxic levels. Prolonged serum concentrations above 12 μg/mL should be avoided. Rising trough levels (above 2 μg/mL) may indicate tissue accumulation. Such accumulation, excessive peak concentrations, advanced age, and cumulative dose may contribute to ototoxicity and nephrotoxicity (see PRECAUTIONS). Urine should be examined for decreased specific gravity and increased excretion of protein, cells, and casts. Blood urea nitrogen, serum creatinine, and creatinine clearance should be measured periodically. When feasible, it is 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 the drug or dosage adjustment.
Tobramycin should be used with caution in premature and neonatal infants because of their renal immaturity and the resulting prolongation of serum half-life of the drug.
Concurrent and sequential use of other neurotoxic and/or nephrotoxic antibiotics, particularly other aminoglycosides (e.g., amikacin, streptomycin, neomycin, kanamycin, gentamicin, and paromomycin), cephaloridine, viomycin, polymyxin B, colistin, cisplatin, and vancomycin, should be avoided. Other factors that may increase patient risk are advanced age and dehydration.
Aminoglycosides should not be given concurrently with potent diuretics, such as ethacrynic acid and furosemide. Some diuretics themselves cause ototoxicity, and intravenously administered diuretics enhance aminoglycoside toxicity by altering antibiotic concentrations in serum and tissue.
Aminoglycosides can cause fetal harm when administered to a pregnant woman (see PRECAUTIONS).
Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Tobramycin, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the 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 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.
Tobramycin sulfate, a water-soluble antibiotic of the aminoglycoside group, is derived from the actinomycete Streptomyces tenebrarius. Tobramycin in 0.9% Sodium Chloride Injection is a clear and colorless sterile aqueous solution for parenteral administration.
Each milliliter (mL) of the 50 mL size contains tobramycin sulfate equivalent to 1.2 mg tobramycin base with sodium chloride 9 mg in water for injection.
Each milliliter (mL) of the 100 mL size contains tobramycin sulfate equivalent to 0.8 mg tobramycin base with sodium chloride 9 mg in water for injection.
For the 50 and 100 mL sizes, the osmolar concentration is listed in the HOW SUPPLIED section; pH is 5.0 (3.0 to 6.5). Contains sulfuric acid and may contain sodium hydroxide for pH adjustment.
The solutions contain no bacteriostat, antimicrobial agent (except tobramycin) or buffer and are intended only for use as a single-dose infusion. When smaller doses are required the unused portion should be discarded.
Tobramycin sulfate is O - 3 - amino - 3 - deoxy - α - D - glucopyranosyl - (1→4) - O - [2,6 - diamino - 2,3,6 - trideoxy - α - D - ribo - hexopyranosyl - (1→6)] - 2 - deoxy - L - streptamine sulfate (2:5)(salt) and has the chemical formula (C18H37N5O9)2 • 5H2SO4. The molecular weight is 1,425.39. The structural formula for tobramycin is as follows:
The flexible plastic container is fabricated from a specially formulated polyvinyl chloride. Water can permeate from inside the container into the overwrap but not in amounts sufficient to affect the solution significantly.
Solutions in contact with the plastic container may leach out certain chemical components from the plastic in very small amounts; however, biological testing was supportive of the safety of the plastic container materials.
Exposure to temperatures above 25°C/77°F during transport and storage will lead to minor losses in moisture content. Higher temperatures lead to greater losses. It is unlikely that these minor losses will lead to clinically significant changes within the expiration period.
When tobramycin sulfate is administered by intravenous infusion over a one hour period, the serum concentrations are similar to those obtained by intramuscular administration. Following an infusion of 1 mg/kg of body weight, maximum serum concentrations reach about 4 mcg/mL, and measurable levels persist for as long as 8 hours. Therapeutic serum levels are generally considered to range from 4 to 6 mcg/mL. Tobramycin is poorly absorbed from the gastrointestinal tract.
In patients with normal renal function, except neonates, tobramycin sulfate administered every 8 hours does not accumulate in the serum. However, in those patients with reduced renal function and in neonates, the serum concentration of the antibiotic is usually higher and can be measured for longer periods of time than in normal adults. Dosage for such patients must, therefore, be adjusted accordingly (see DOSAGE AND ADMINISTRATION).
Following parenteral administration, little, if any, metabolic transformation occurs, and tobramycin is eliminated almost exclusively by glomerular filtration. Renal clearance is similar to that of endogenous creatinine. Ultrafiltration studies demonstrate that practically no serum protein binding occurs. In patients with normal renal function, up to 84% of the dose is recoverable from the urine in 8 hours and up to 93% in 24 hours.
Peak urine concentrations ranging from 75 to 100 μg/mL have been observed following the intramuscular injection of a single dose of 1 mg/kg. After several days of treatment, the amount of tobramycin excreted in the urine approaches the daily dose administered. When renal function is impaired, excretion of tobramycin sulfate is slowed, and accumulation of the drug may cause toxic blood levels.
The serum half-life in normal individuals is 2 hours. An inverse relationship exists between serum half-life and creatinine clearance, and the dosage schedule should be adjusted according to the degree of renal impairment (see DOSAGE AND ADMINISTRATION). In patients undergoing dialysis, 25% to 70% of the administered dose may be removed, depending on the duration and type of dialysis.
Tobramycin can be detected in tissues and body fluids after parenteral administration. Concentrations in bile and stools ordinarily have been low, which suggests minimum biliary excretion. Tobramycin has appeared in low concentration in the cerebrospinal fluid following parenteral administration, and concentrations are dependent on dose, rate of penetration, and degree of meningeal inflammation. It has also been found in sputum, peritoneal fluid, synovial fluid, and abscess fluids, and it crosses the placental membranes. Concentrations in the renal cortex are several times higher than the usual serum levels.
Probenecid does not affect the renal tubular transport of tobramycin.
Microbiology
Tobramycin is an aminoglycoside antibiotic with activity against Gram-positive and Gram-negative bacteria.
Mechanism of Action
Tobramycin acts by inhibiting synthesis of protein in bacterial cells. In vitro tests demonstrate that tobramycin is bactericidal.
Interactions with Other Antibiotics
Although most strains of enterococci demonstrate in vitro resistance, some strains in this group are susceptible. In vitro studies have shown that an aminoglycoside combined with an antibiotic that interferes with cell-wall synthesis affects some enterococcal strains synergistically. The combination of penicillin G and tobramycin results in a synergistic bactericidal effect in vitro against certain strains of Enterococcus faecalis. However, this combination is not synergistic against other closely related organisms, e.g. Enterococcus faecium. Speciation of enterococci alone cannot be used to predict susceptibility. Susceptibility testing and tests for antibiotic synergism are emphasized.
Cross-Resistance
Cross-resistance between aminoglycosides may occur.
Tobramycin has been shown to be active against most strains of the following organisms both in vitro and in clinical infections: (see INDICATIONS AND USAGE).
Aerobic and facultative Gram-positive microorganisms
Staphylococcus aureus
Aerobic and facultative Gram-negative microorganisms
Citrobacter sp
Enterobacter sp
Escherichia coli
Klebsiella sp
Morganella morganii
Pseudomonas aeruginosa
Proteus mirabilis
Proteus vulgaris
Providencia sp
Serratia sp
Aminoglycosides have a low order of activity against most Gram-positive organisms, including Streptococcus pyogenes, Streptococcus pneumoniae, and enterococci.
Susceptibility Tests:
When available, the clinical microbiology laboratory should provide cumulative results of the in vitro susceptibility test results for antimicrobial drugs used in resident hospitals to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting the most effective antimicrobial.
Dilution Techniques:
Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized procedure. Standardized procedures are based on a dilution method (broth or agar)1 or equivalent with standardized inoculum concentrations and standardized concentrations of tobramycin powder. The MIC values should be interpreted according to the criteria provided in Table 1.
Diffusion Technique:
Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure2 requires the use of standardized inoculum concentrations. This procedure uses paper disks impregnated with 10 mcg of tobramycin to test the susceptibility of microorganisms to tobramycin. The disk diffusion interpretive criteria are provided in Table 1.
Pathogen | Susceptibility Interpretive Criteria | |||||
Minimum Inhibitory Concentration (mcg/mL) | Disk Diffusion Zone Diameter (mm) | |||||
S | I | R | S | I | R | |
Staphylococcus spp. | ≤4 | 8 | ≥16 | ≥15 | 13-14 | ≤12 |
Enterobacteriaceae | ≤4 | 8 | ≥16 | ≥15 | 13-14 | ≤12 |
Pseudomonas aeruginosa | ≤4 | 8 | ≥16 | ≥15 | 13-14 | ≤12 |
A report of Susceptible indicates that the antimicrobial is likely to inhibit growth of the pathogen if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of Intermediate indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where a high dosage of drug can be used. This category also provides a buffer zone, which prevents small, uncontrolled technical factors from causing major discrepancies in interpretation. A report of Resistant indicates that the antimicrobial is not likely to inhibit growth of the pathogen if the antimicrobial compound in the blood reaches the concentrations usually achievable and other therapy should be selected.
Quality Control:
Standardized susceptibility test procedures require the use of quality control microorganisms to control the technical aspects of the test procedures3. Standard tobramycin powder should provide the following range of values noted in Table 2.
QC Strain | Acceptable Quality Control Ranges | |
Minimum Inhibitory Concentration (mcg/mL) | Disk Diffusion Zone Diameter (mm) | |
Staphylococcus aureus ATCC 29213 | 0.12 - 1 | NAa |
Staphylococcus aureus ATCC 25923 | NA | 19 - 29 |
Escherichia coli ATCC 25922 | 0.25 - 1 | 18 - 26 |
Pseudomonas aeruginosa ATCC 27853 | 0.25 - 1 | 19 - 25 |
a not applicable | ||
Tobramycin sulfate is indicated for the treatment of serious bacterial infections caused by susceptible strains of the designated microorganisms in the diseases listed below:
Septicemia in the neonate, child, and adult caused by P aeruginosa, E coli, and Klebsiella sp
Lower respiratory tract infections caused by P aeruginosa, Klebsiella sp, Enterobacter sp, Serratia sp, E coli, and S aureus (penicillinase and non-penicillinase-producing strains)
Serious central-nervous-system infections (meningitis) caused by susceptible organisms
Intra-abdominal infections, including peritonitis, caused by E coli, Klebsiella sp, and Enterobacter sp
Skin, bone, and skin-structure infections caused by P aeruginosa, Proteus sp, E coli, Klebsiella sp, Enterobacter sp, and S aureus
Complicated and recurrent urinary tract infections caused by P aeruginosa, Proteus sp (indole-positive and indole-negative), E coli, Klebsiella sp, Enterobacter sp, Serratia sp, S aureus, Providencia sp, and Citrobacter sp
Aminoglycosides, including tobramycin sulfate, are not indicated in uncomplicated initial episodes of urinary tract infections unless the causative organisms are not susceptible to antibiotics having less potential toxicity. Tobramycin sulfate may be considered in serious staphylococcal infections when penicillin or other potentially less toxic drugs are contraindicated and when bacterial susceptibility testing and clinical judgment indicate its use.
Bacterial cultures should be obtained prior to and during treatment to isolate and identify etiologic organisms and to test their susceptibility to tobramycin. If susceptibility tests show that the causative organisms are resistant to tobramycin, other appropriate therapy should be instituted. In patients in whom a serious life-threatening gram-negative infection is suspected, including those in whom concurrent therapy with a penicillin or cephalosporin and an aminoglycoside may be indicated, treatment with tobramycin sulfate may be initiated before the results of susceptibility studies are obtained. The decision to continue therapy with tobramycin should be based on the results of susceptibility studies, the severity of the infection, and the important additional concepts discussed in the WARNINGS box above.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of tobramycin and other antibacterial drugs, tobramycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antimicrobial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
A hypersensitivity to any aminoglycoside is a contraindication to the use of tobramycin. A history of hypersensitivity or serious toxic reactions to aminoglycosides may also contraindicate the use of any other aminoglycoside because of the known cross-sensitivity of patients to drugs in this class.
See WARNINGS box above.
Serum and urine specimens for examination should be collected during therapy, as recommended in the WARNINGS box. Serum calcium, magnesium, and sodium should be monitored.
Peak and trough serum levels should be measured periodically during therapy. Prolonged concentrations above 12 μg/mL should be avoided. Rising trough levels (above 2 μg/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 the dosage could be adjusted if necessary, and also 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 the guidelines provided in the DOSAGE AND ADMINISTRATION section.
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 the next dose of tobramycin. These suggested time intervals are intended only as guidelines and may vary according to institutional practices. It is important, however, that there be consistency within the individual patient program unless computerized pharmacokinetic dosing programs are available in the institution. These serum-level assays may be especially useful for monitoring the treatment of severely ill patients with changing renal function or of those infected with less sensitive organisms or those receiving maximum dosage.
Neuromuscular blockade and respiratory paralysis have been reported in cats receiving very high doses of tobramycin (40 mg/kg). The 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, it may be reversed by the administration of calcium salts.
Cross-allergenicity among aminoglycosides has been demonstrated.
In patients with extensive burns, 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 the 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 has been 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 their 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.
See WARNINGS box regarding concurrent use of potent diuretics and concurrent and sequential use of other neurotoxic or nephrotoxic drugs.
The inactivation of tobramycin and other aminoglycosides by β-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.
Pregnancy Category D — Aminoglycosides can cause fetal harm when administered to a pregnant woman. Aminoglycoside antibiotics cross the placenta, and there have been several reports of total irreversible bilateral congenital deafness in children whose mothers received streptomycin during pregnancy. Serious side effects to mother, fetus, or newborn have not been reported in the treatment of pregnant women with other aminoglycosides. If tobramycin is used during pregnancy or if the patient becomes pregnant while taking tobramycin, she should be apprised of the potential hazard to the fetus.
Usage in Children — See INDICATIONS AND USAGE and DOSAGE AND ADMINISTRATION.
Prescribing tobramycin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
Patients should be counseled that antibacterial drugs including tobramycin should only be used to treat bacterial infections. They do not treat viral infections (e.g. the common cold). When an antibacterial drug product is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by tobramycin or other antibacterial drugs in the future.
Diarrhea is a common problem caused by antibiotics, which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.
Neurotoxicity — Adverse effects on both the vestibular and auditory branches of the eighth nerve have been noted, especially in patients receiving high doses or prolonged therapy, in those given previous courses of therapy with an ototoxin, and in cases of dehydration. Symptoms include dizziness, vertigo, tinnitus, roaring in the ears, and hearing loss. Hearing loss is usually irreversible and is manifested initially by diminution of high-tone acuity. Tobramycin and gentamicin sulfates closely parallel each other in regard to ototoxic potential.
Nephrotoxicity — Renal function changes, as shown by rising BUN, NPN, and serum creatinine and by oliguria, cylindruria, and increased proteinuria, have been reported, especially in patients with a history of renal impairment who are treated for longer periods or with higher doses than those recommended. Adverse renal effects can occur in patients with initially normal renal function.
Clinical studies and studies in experimental animals have been conducted to compare the nephrotoxic potential of tobramycin and gentamicin. In some of the clinical studies and in the animal studies, tobramycin caused nephrotoxicity significantly less frequently than gentamicin. In some other clinical studies, no significant difference in the incidence of nephrotoxicity between tobramycin and gentamicin was found.
Other reported adverse reactions possibly related to tobramycin sulfate include anemia, granulocytopenia, and thrombocytopenia; and fever, rash, itching, urticaria, nausea, vomiting, diarrhea, headache, lethargy, pain at the injection site, mental confusion, and disorientation. Laboratory abnormalities possibly related to tobramycin sulfate include increased serum transaminases (SGOT, SGPT); increased serum LDH and bilirubin; decreased serum calcium, magnesium, sodium, and potassium; and leukopenia, leukocytosis, and eosinophilia.
Signs and Symptoms — The severity of the signs and symptoms following a tobramycin overdose are dependent on the dose administered, the patient’s renal function, state of hydration, and age and whether or not other medications with similar toxicities are being administered concurrently. Toxicity may occur in patients treated more than 10 days, in adults given more than 5 mg/kg/day, children given more than 7.5 mg/kg/day, or patients with reduced renal function whose dose has not been appropriately adjusted.
Nephrotoxicity following the parenteral administration of an aminoglycoside is most closely related to the area under the curve of the serum concentration versus time graph. Nephrotoxicity is more likely if trough blood concentrations fail to fall below 2 μg/mL and is also proportional to the average blood concentration. Patients who are elderly, have abnormal renal function, are receiving other nephrotoxic drugs, or are volume depleted are at greater risk for developing acute tubular necrosis. Auditory and vestibular toxicity has been associated with aminoglycoside overdose; these toxicities occur in patients treated longer than 10 days, in patients with abnormal renal function, in dehydrated patients, or in patients receiving medications with additive auditory toxicities. These patients may not have signs or symptoms or may experience dizziness, tinnitus, vertigo, and a loss of high-tone acuity, as ototoxicity progresses. Ototoxicity signs and symptoms may not begin to occur until long after the drug has been discontinued.
Neuromuscular blockade or respiratory paralysis may occur following administration of many aminoglycosides. Neuromuscular blockade, respiratory failure, and prolonged respiratory paralysis may occur more commonly in patients with myasthenia gravis or Parkinson’s disease. Prolonged respiratory paralysis may also occur in patients receiving decamethonium, tubocurarine, or succinylcholine. If neuromuscular blockade occurs, it may be reversed by the administration of calcium salts but mechanical assistance may be necessary.
If tobramycin were ingested, toxicity would be less likely because aminoglycosides are poorly absorbed from an intact gastrointestinal tract.
Treatment — In all cases of suspected overdosage, call your Regional Poison Control Center to obtain the most up-to-date information about the treatment of overdose. This recommendation is made because, in general, information regarding the treatment of overdose may change more rapidly than the package insert. In managing overdosage, consider the possibility of multiple drug overdoses, interaction among drugs, and unusual drug kinetics in your patient.
The initial intervention in a tobramycin overdose is to establish an airway and ensure oxygenation and ventilation. Resuscitative measures should be initiated promptly if respiratory paralysis occurs.
Patients that have received an overdose of tobramycin and have normal renal function should be adequately hydrated to maintain a urine output of 3 to 5 mL/kg/hr. Fluid balance, creatinine clearance, and tobramycin plasma levels should be carefully monitored until the serum tobramycin level falls below 2 μg/mL.
Patients in whom the elimination half-life is greater than 2 hours or whose renal function is abnormal may require more aggressive therapy. In such patients, hemodialysis may be beneficial.
Tobramycin sulfate injection may be given intramuscularly or intravenously. Recommended dosages are the same for both routes.
Tobramycin in 0.9% Sodium Chloride Injection is administered by intravenous infusion only. The patient’s pretreatment body weight should be obtained for calculation of correct dosage. It is desirable to measure both peak and trough serum concentrations (see WARNINGS box and PRECAUTIONS).
Administration for Patients with Normal Renal Function — Adults with Serious Infections: 3 mg/kg/day in 3 equal doses every 8 hours (see Table 3).
Adults with Life-Threatening Infections: Up to 5 mg/kg/day may be administered in 3 or 4 equal doses (see Table 3). The dosage should be reduced to 3 mg/kg/day as soon as clinically indicated. To prevent increased toxicity due to excessive blood levels, dosage should not exceed 5 mg/kg/day unless serum levels are monitored (see WARNINGS box and PRECAUTIONS).
For Patient | Usual Dose for Serious Infections | Maximum Dose for Life- Threatening Infections (Reduce as soon as possible) | |||
Weighing | 1 mg/kg | q8h | 1.66 mg/kg | q8h | |
kg | lb | (Total, 3 mg/kg/day) | (Total, 5 mg/kg/day) | ||
mg/dose | mg/dose | ||||
120 | 264 | 120 mg | 200 mg | ||
115 | 253 | 115 mg | 191 mg | ||
110 | 242 | 110 mg | 183 mg | ||
105 | 231 | 105 mg | 175 mg | ||
100 | 220 | 100 mg | 166 mg | ||
95 | 209 | 95 mg | 158 mg | ||
90 | 198 | 90 mg | 150 mg | ||
85 | 187 | 85 mg | 141 mg | ||
80 | 176 | 80 mg | 133 mg | ||
75 | 165 | 75 mg | 125 mg | ||
70 | 154 | 70 mg | 116 mg | ||
65 | 143 | 65 mg | 108 mg | ||
60 | 132 | 60 mg | 100 mg | ||
55 | 121 | 55 mg | 91 mg | ||
50 | 110 | 50 mg | 83 mg | ||
45 | 99 | 45 mg | 75 mg | ||
40 | 88 | 40 mg | 66 mg | ||
Note: For information concerning the use of tobramycin in infants and children, see Pediatric tobramycin product information.
Children: 6 to 7.5 mg/kg/day in 3 or 4 equally divided doses (2 to 2.5 mg/kg every 8 hours or 1.5 to 1.89 mg/kg every 6 hours).
Premature or Full-Term Neonates 1 Week of Age or Less: Up to 4 mg/kg/day may be administered in 2 equal doses every 12 hours.
It is desirable to limit treatment to a short term. The usual duration of treatment is 7 to 10 days. A longer course of therapy may be necessary in difficult and complicated infections. In such cases, monitoring of renal, auditory, and vestibular functions is advised, because neurotoxicity is more likely to occur when treatment is extended longer than 10 days.
Administration for Patients With Impaired Renal Function — Whenever possible, serum tobramycin concentrations should be monitored during therapy.
Following a loading dose of 1 mg/kg, subsequent dosage in these patients must be adjusted, either with reduced doses administered at 8-hour intervals or with normal doses given at prolonged intervals. Both of these methods are suggested as guides to be used when serum levels of tobramycin cannot be measured directly. They are based on either the creatinine clearance or the serum creatinine of the patient, because these values correlate with the half-life of tobramycin. The dosage schedules derived from either method should be used in conjunction with careful clinical and laboratory observations of the patient and should be modified as necessary. Neither method should be used when dialysis is being performed.
Reduced dosage at 8-hour intervals: When the creatinine clearance rate is 70 mL or less per minute or when the serum creatinine value is known, the amount of the reduced dose can be determined by multiplying the normal dose from Table 3 by the percent of normal dose from the accompanying nomogram.
An alternate rough guide for determining reduced dosage at 8-hour intervals (for patients whose steady-state serum creatinine values are known) is to divide the normally recommended dose by the patient’s serum creatinine.
Normal dosage at prolonged intervals: If the creatinine clearance rate is not available and the patient’s condition is stable, a dosage frequency in hours for the dosage given in Table 3 can be determined by multiplying the patient’s serum creatinine by 6.
Dosage in Obese Patients — The appropriate dose may be calculated by using the patient’s estimated lean body weight plus 40% of the excess as the basic weight on which to figure mg/kg.
Intravenous Administration — For intravenous administration, the usual volume of diluent (0.9% Sodium Chloride Injection or 5% Dextrose Injection) is 50 to 100 mL for adult doses. For children, the volume of diluent should be proportionately less than for adults. The diluted solution usually should be infused over a period of 20 to 60 minutes. Infusion periods of less than 20 minutes are not recommended because peak serum levels may exceed 12 mcg/mL (see WARNINGS box).
Tobramycin in 0.9% Sodium Chloride Injection should not be physically premixed with other drugs but should be administered separately according to the recommended dose and route.
The above schedules are not intended as rigid recommendations but are provided as guides to dosage when the measurement of tobramycin sulfate serum levels is not feasible.
A variety of methods are available to measure tobramycin concentrations in body fluids; these include microbiology, enzymatic and radioimmunoassay techniques.
Tobramycin in 0.9% Sodium Chloride Injection is a ready-to-use isotonic solution. NO DILUTION OR BUFFERING IS REQUIRED.
If the prescribed dose is exactly 60 or 80 mg, use the appropriate container. If the prescribed dose is higher or lower than that of the supplied containers, adjustments can be made in either container. If the dose is higher than the contents of the 80 mg container, the additional amount should be removed from a container of tobramycin and added to the 80 mg container. If the prescribed dose is less, decrements can be made by removing and discarding the appropriate amount from either unit.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. See CONTRAINDICATIONS.
INSTRUCTIONS FOR USE
To Open
Tear outer wrap at notch and remove solution container. Some opacity of the plastic due to moisture absorption during the sterilization process may be observed. This is normal and does not affect the solution quality or safety. The opacity will diminish gradually.
Preparation for Administration
(Use aseptic technique)
Close flow control clamp of administration set.
Remove cover from outlet port at bottom of container.
Insert piercing pin of administration set into port with a twisting motion until the set is firmly seated. Note: See full directions on administration set carton.
Suspend container from hanger.
Squeeze and release drip chamber to establish proper fluid level in chamber.
Open flow control clamp and clear air from set. Close clamp.
Attach set to venipuncture device. If device is not indwelling, prime and make venipuncture.
Regulate rate of administration with flow control clamp.
WARNING: Do not use flexible container in series connections.
Tobramycin in 0.9% Sodium Chloride Injection is supplied in a single-dose flexible container as follows:
NDC No. |
