Tobramycin Side Effects

It is possible that some side effects of tobramycin may not have been reported. These can be reported to the FDA here. Always consult a healthcare professional for medical advice.

For the Consumer

Applies to tobramycin: inhalation capsule, inhalation solution

As well as its needed effects, tobramycin may cause unwanted side effects that require medical attention.

If any of the following side effects occur while taking tobramycin, check with your doctor immediately:

More common
  • Bloody nose
  • difficulty with breathing
  • discoloration of sputum
  • fever
  • runny nose
  • sneezing
  • stuffy nose
  • voice changes
Less common
  • Black, tarry stools
  • chest pain
  • chills
  • continuing ringing or buzzing or other unexplained noise in the ears
  • hearing loss
  • painful or difficult urination
  • shortness of breath
  • sore throat
  • sores, ulcers, or white spots on the lips or in the mouth
  • swollen glands
  • tightness in the chest
  • unusual bleeding or bruising
  • unusual tiredness or weakness

If any of the following symptoms of overdose occur while taking tobramycin, get emergency help immediately:

Symptoms of overdose
  • Blue lips, fingernails, or skin
  • dizziness or lightheadedness
  • drowsiness
  • feeling of constant movement of self or surroundings
  • irregular, fast or slow, or shallow breathing
  • sensation of spinning

Some tobramycin side effects may not need any medical attention. As your body gets used to the medicine these side effects may disappear. Your health care professional may be able to help you prevent or reduce these side effects, but do check with them if any of the following side effects continue, or if you are concerned about them:

More common
  • Back pain
  • general feeling of discomfort or illness
  • hoarseness
Less common
  • Bloody nose
  • change or loss of taste
  • diarrhea
  • rash

For Healthcare Professionals

Applies to tobramycin: compounding powder, inhalation capsule, inhalation solution, injectable powder for injection, injectable solution, intravenous solution

Nervous system

Very common (10% or more):
-TOBI(R): Headache (12%)
-TOBI(R) Podhaler(TM): Headache (11.4%), hypoacusis (10%)

Common (1% to 10%):
-TOBI(R): Tinnitus (up to 3.1%)
-TOBI(R) Podhaler(TM): Tinnitus (1.9%), deafness including unilateral deafness (reported as mild to moderate hearing loss or increased hearing loss; 1%)

Uncommon (0.1% to 1%):
-TOBI(R): Deafness including unilateral deafness (reported as mild to moderate hearing loss or increased hearing loss; 0.5%)

Rare (less than 0.1%):
-Neuromuscular blockade

Frequency not reported:
-Parenteral: Neurotoxicity, eighth-nerve impairment (auditory and vestibular ototoxicity), cochlear hair cell damage, dizziness, vertigo, roaring in ears, hearing loss, numbness, skin tingling, muscle twitching, convulsions, headache
-Inhalation: Transient tinnitus, tinnitus, hearing loss, headache, ototoxicity

Postmarketing reports:
-Inhalation: Hearing loss, tinnitus, aphonia, dysgeusia[Ref]

Parenteral: Ototoxicity may have included loss of auditory or vestibular function secondary to cochlear hair cell damage. Partial or total auditory changes were irreversible and usually bilateral; deafness may have continued to develop after drug was stopped. Eighth-nerve impairment primarily occurred in patients with preexisting renal damage, with normal renal function treated for longer periods and/or at higher doses than recommended, who previously received an ototoxic agent, and who were dehydrated. Risk of drug-induced hearing loss increased with extent of exposure to high peak or high trough serum levels. Ototoxicity may be less likely when tobramycin serum trough levels are less than 2 mg/L after parenteral administration.

Inhalation: Tinnitus may be a sentinel symptom of ototoxicity. Some patients who concurrently received, or previously had prolonged therapy with, parenteral aminoglycosides reported hearing loss.

Rare neurologic side effects have included neuromuscular blockade, particularly in patients who were predisposed, including patients with myasthenia gravis, hypocalcemia, and those receiving a neuromuscular blocking agent.

Headache has been reported in patients using inhaled tobramycin with ciprofloxacin for non-cystic fibrosis bronchiectasis.[Ref]

Renal

Rare (less than 0.1%):
-Inhalation: Acute renal failure

Frequency not reported:
-Parenteral: Nephrotoxicity (usually reversible), renal function changes, rising BUN, rising non-protein nitrogen, rising serum creatinine, oliguria, cylindruria, increased proteinuria[Ref]

Nephrotoxicity primarily occurred in patients with preexisting renal damage and in patients with normal renal function treated for longer periods and/or at higher doses than recommended. Predisposing factors also included advanced age, dehydration, and concomitant use of other potentially nephrotoxic drugs.

The overall incidence of aminoglycoside nephrotoxicity was 2% to 10%, and increased if tobramycin trough levels exceeded 2 mg/L. One study showed that hyperbilirubinemia in patients with biliary obstruction predisposed to aminoglycoside nephrotoxicity.

A 62-year-old female with multiple comorbidities, including chronic renal insufficiency, was started on inhaled tobramycin for healthcare-associated pneumonia. The patient continued inhaled tobramycin for 27 days, during which her serum creatinine gradually rose. After reaching a serum creatinine level of 4.5 mg/dL, the inhaled tobramycin was discontinued on day 28 and the patient was started on hemodialysis due to acute renal failure.[Ref]

Respiratory

Very common (10% or more):
-Bethkis(R): Decreased forced expiratory volume (31%), rales (19%)
-TOBI(R): Cough (31.1%), lung disorder (including pulmonary or cystic fibrosis exacerbations; 30.1%), productive cough (19.6%), dyspnea (12.4%), hemoptysis (12.4%), oropharyngeal pain (10.5%)
-TOBI(R) Podhaler(TM): Cough (up to 48.8%), lung disorder (including pulmonary or cystic fibrosis exacerbations; 33.8%), productive cough (18.2%), dyspnea (15.6%), oropharyngeal pain (14%), dysphonia (up to 13.6%), hemoptysis (13%), pharyngolaryngeal pain (10.9%)

Common (1% to 10%):
-Bethkis(R): Dysphonia (6%), wheezing (5%), epistaxis (3%), pharyngolaryngeal pain (3%), bronchitis (3%), tonsillitis (2%)
-TOBI(R): Upper respiratory tract infection (8.6%), decreased pulmonary function test (8.1%), nasal congestion (7.2%), rales (6.2%), wheezing (6.2%), laryngitis (4.3%), voice alteration/dysphonia (3.8%), chest discomfort (2.9%), throat irritation (1.9%), epistaxis (1.9%), decreased forced expiratory volume (1%), sputum discoloration
-TOBI(R) Podhaler(TM): Nasal congestion (8.1%), rales (7.1%), wheezing (6.8%), upper respiratory tract infection (6.8%), decreased pulmonary function test (6.8%), chest discomfort (6.5%), throat irritation (4.5%), decreased forced expiratory volume (3.9%), epistaxis (2.6%), bronchospasm (1.6%)

Uncommon (0.1% to 1%):
-TOBI(R): Bronchospasm (0.5%), rhinitis, decreased lung function

Frequency not reported:
-Inhalation: Wheeze, cough, dyspnea

Postmarketing reports:
-Inhalation: Bronchospasm, oropharyngeal pain[Ref]

Decreased lung function included reported decreases in pulmonary function tests or decreased lung volume on chest radiograph associated with intercurrent illness or study drug administration.

Bronchospasm has been reported with nebulized tobramycin in cystic fibrosis patients. To help prevent bronchospasm, a bronchodilator should be used in conjunction with nebulized tobramycin. The preserved parenteral formulation has been associated with more bronchospasm than the preservative-free solution for inhalation.

Wheeze, cough, and dyspnea have been reported in patients using inhaled tobramycin with ciprofloxacin for non-cystic fibrosis bronchiectasis.[Ref]

Hypersensitivity

Rare (less than 0.1%):
-Parenteral: Serious allergic reactions (including anaphylaxis and dermatologic reactions), allergic-type reactions (including anaphylactic symptoms and life-threatening or less severe asthmatic episodes)
-Hypersensitivity reactions (including eosinophilia, pruritus, fever, rash, exfoliative dermatitis)

Frequency not reported:
-Cross-sensitivity among aminoglycosides

Postmarketing reports:
-Inhalation: Hypersensitivity[Ref]

Severe and sometimes fatal allergic reactions (including anaphylaxis and dermatologic reactions including exfoliative dermatitis, toxic epidermal necrolysis, erythema multiforme, and Stevens-Johnson syndrome) have been reported rarely.

The sodium metabisulfite preservative in some formulations may cause allergic-type reactions (including anaphylactic symptoms and life-threatening or less severe asthmatic episodes) in some susceptible patients.[Ref]

Dermatologic

Contact dermatitis in a patient using tobramycin-containing ear drops has been reported.

A case of exfoliative dermatitis was associated with IV and intraperitoneal tobramycin.[Ref]

Common (1% to 10%):
-TOBI(R): Rash (2.4%)
-TOBI(R) Podhaler(TM): Rash (2.3%)

Rare (less than 0.1%):
-Parenteral: Exfoliative dermatitis, toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome
-Contact dermatitis (at least 1 case)

Frequency not reported:
-Parenteral: Rash, itching, urticaria

Postmarketing reports:
-Inhalation: Pruritus, urticaria, rash[Ref]

Other

Toxic trough levels have been reported with nebulized tobramycin administered by positive pressure ventilation to a patient with renal dysfunction. No symptoms of toxicity were noted.

Fatigue has been reported in patients using inhaled tobramycin with ciprofloxacin for non-cystic fibrosis bronchiectasis.[Ref]

Very common (10% or more):
-TOBI(R): Pyrexia (12.4%)
-TOBI(R) Podhaler(TM): Pyrexia (15.6%)

Uncommon (0.1% to 1%):
-TOBI(R): Malaise

Frequency not reported:
-Parenteral: Fever
-Inhalation: Toxic trough levels, fatigue[Ref]

Gastrointestinal

Nausea has been reported in patients using inhaled tobramycin with ciprofloxacin for non-cystic fibrosis bronchiectasis.[Ref]

Common (1% to 10%):
-Bethkis(R): Diarrhea (2%)
-TOBI(R): Nausea (9.6%), vomiting (5.7%), diarrhea (1.9%)
-TOBI(R) Podhaler(TM): Nausea (7.5%), vomiting (6.2%), diarrhea (4.2%), dysgeusia (up to 6.5%)

Uncommon (0.1% to 1%):
-TOBI(R): Dysgeusia (0.5%)

Frequency not reported:
-Parenteral: Nausea, vomiting, diarrhea, Clostridium difficile associated diarrhea
-Inhalation: Nausea[Ref]

Hematologic

Common (1% to 10%):
-Bethkis(R): Increased red blood cell sedimentation rate (8%), eosinophilia (2%)

Frequency not reported:
-Parenteral: Anemia, granulocytopenia, thrombocytopenia, leukopenia, leukocytosis, eosinophilia[Ref]

Metabolic

Renal tubular toxicity may have resulted in renal magnesium wasting, which may have resulted in hypocalcemia (due to magnesium-dependent parathormone secretion) and clinical tetany in rare cases.[Ref]

Common (1% to 10%):
-TOBI(R) Podhaler(TM): Increased blood glucose (2.9%)

Uncommon (0.1% to 1%):
-TOBI(R): Increased blood glucose (0.5%)

Rare (less than 0.1%):
-Clinical tetany

Frequency not reported:
-Parenteral: Increased serum lactate dehydrogenase, decreased serum calcium, decreased serum magnesium, decreased serum sodium, decreased serum potassium
-Hypophosphatemia[Ref]

Musculoskeletal

Common (1% to 10%):
-TOBI(R): Musculoskeletal chest pain (4.8%), myalgia (4.7%)
-TOBI(R) Podhaler(TM): Musculoskeletal chest pain (4.5%)[Ref]

Hepatic

Rare (less than 0.1%):
-Parenteral: Elevated liver function tests, hepatotoxicity

Frequency not reported:
-Parenteral: Increased serum transaminases (AST, ALT), increased serum bilirubin[Ref]

Immunologic

Common (1% to 10%):
-Bethkis(R): Increased immunoglobulins (2%)

Psychiatric

Rare (less than 0.1%):
-Delirium

Frequency not reported:
-Parenteral: Lethargy, mental confusion, disorientation[Ref]

A rare case of delirium has been reported in a patient who was receiving tobramycin, but there was concomitant opiate administration and underlying infection, which makes implication of tobramycin difficult.[Ref]

Local

Frequency not reported:
-Parenteral: Pain at injection site[Ref]

References

1. "Product Information. Nebcin (tobramycin)." Lilly, Eli and Company, Indianapolis, IN.

2. Tablan OC, Reyes MP, Rintelmann WF, Lerner AM "Renal and auditory toxicity of high-dose, prolonged therapy with gentamicin and tobramycin in pseudomonas endocarditis." J Infect Dis 149 (1984): 257-63

3. Mulheran M, Degg C, Burr S, Morgan DW, Stableforth DE "Occurrence and risk of cochleotoxicity in cystic fibrosis patients receiving repeated high-dose aminoglycoside therapy." Antimicrob Agents Chemother 45 (2001): 2502-9

4. Ariano RE, Zelenitsky SA, Kassum DA "Aminoglycoside-induced vestibular injury: maintaining a sense of balance." Ann Pharmacother 42 (2008): 1282-9

5. Izquierdo MJ, Gomez-Alamillo C, Ortiz F, et al. "Acute renal failure associated with use of inhaled tobramycin for treatment of chronic airway colonization with Pseudomonas aeruginosa." Clin Nephrol 66 (2006): 464-7

6. McCartney CF, Halley LH, Kessler JM "Possible tobramycin delirium." JAMA 247 (1982): 1319

7. Mulheran M, Hyman-Taylor P, Tan KH, et al. "Absence of Cochleotoxicity Measured by Standard and High-Frequency Pure Tone Audiometry in a Trial of Once- versus Three-Times-Daily Tobramycin in Cystic Fibrosis Patients." Antimicrob Agents Chemother 50 (2006): 2293-9

8. Bilton D, Henig N, Morrissey B, Gotfried M "Addition of Inhaled Tobramycin to Ciprofloxacin for Acute Exacerbations of Pseudomonas aeruginosa Infection in Adult Bronchiectasis." Chest 130 (2006): 1503-10

9. Pedersen SS, Jensen J, Osterhammel D, Osterhammel P "Cumulative and acute toxicity of repeated high-dose tobramycin treatment in cystic fibrosis." Antimicrob Agents Chemother 31 (1987): 594-9

10. Uziel A "Non-genetic factors affecting hearing development." Acta Otolaryngol (Stockh) 421 (1985): 57-61

11. Ramakrishnan K, Scheid DC "Diagnosis and management of acute pyelonephritis in adults." Am Fam Physician 71 (2005): 933-42

12. Bernstein JM, Gorse GJ, Linzmayer I, et al "Relative efficacy and toxicity of netilmicin and tobramycin in oncology patients." Arch Intern Med 146 (1986): 2329-34

13. "Product Information. Tobi tobramycin solution for inhalation (tobramycin)" PathoGenesis, Skokie, IL.

14. Nisly SA, Ray SM, Moye RA "Tobramycin-induced hepatotoxicity." Ann Pharmacother 41 (2007): 2061-5

15. Smith CR, Lipsky JJ, Laskin OL, et al "Double-blind comparison of the nephrotoxicity and auditory toxicity of gentamicin and tobramycin." N Engl J Med 302 (1980): 1106-9

16. Gatell JM, SanMiguel JG, Araujo V, et al "Prospective randomized double-blind comparison of nephrotoxicity and auditory toxicity of tobramycin and netilmicin." Antimicrob Agents Chemother 26 (1984): 766-9

17. Pines A, Goldhammer E, Kaplinsky N, Frankl O "Hypopotassemia associated with tobramycin treatment." Infection 10 (1982): 101-

18. Bruun JN, Eng J, Arnesen AR "Tobramycin therapy of serious infections." Scand J Infect Dis 13 (1981): 59-64

19. Barza M, Ioannidis JP, Cappelleri JC, Lau J "Single or multiple daily doses of aminoglycosides: a meta-analysis." BMJ 312 (1996): 338-45

20. Tusar K, Tsang TK "Aminoglycoside nephrotoxicity in obstructive jaundice." Am J Med 85 (1988): 47-50

21. Keys TF, Kurtz SB, Jones JD, Muller SM "Renal toxicity during therapy with gentamicin or tobramycin." Mayo Clin Proc 56 (1981): 556-9

22. Cannella CA, Wilkinson ST "Acute renal failure associated with inhaled tobramycin." Am J Health Syst Pharm 63 (2006): 1858-61

23. Patrick BN, Rivey MP, Allington DR "Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty." Ann Pharmacother 40 (2006): 2037-42

24. Emanuelli G, Anfossi G, Calcamuggi G, Marcarino C, Lanzio M "Urinary enzyme release following aminoglycoside administration in single low dose." Enzyme 39 (1988): 119-22

25. Desai TK, Tsang TK "Aminoglycoside nephrotoxicity in obstructive jaundice." Am J Med 85 (1988): 47-50

26. Schentag JJ, Vari AJ, Winslade NE, et al "Treatment with aztreonam or tobramycin in critical care patients with nosocomial gram-negative pneumonia." Am J Med 78 (1985): 34-41

27. Watson AJ, Watson MM, Keogh JA "Metabolic abnormalities associated with tobramycin therapy." Isr J Med Sci 153 (1984): 96-9

28. Kumin GD "Clinical nephrotoxicity of tobramycin and gentamicin." JAMA 244 (1980): 1808-10

29. Dovas S, Liakopoulos V, Papatheodorou L, et al. "Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty." Clin Nephrol 69 (2008): 207-12

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33. Karp S, Bakris G, Cooney A, et al "Exfoliative dermatitis secondary to tobramycin sulfate." Cutis 47 (1991): 331-2

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