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Streptomycin Dosage

Applies to the following strengths: 1000 mg

Usual Adult Dose for Tuberculosis - Active

Daily dosing: 15 mg/kg IM once a day
-Maximum dose: 1 gram/day

Intermittent dosing: 25 to 30 mg/kg IM 2 to 3 times a week
-Maximum dose: 1.5 grams/dose

Duration of therapy: At least 1 year

Comments:
-Doses should be given in the upper outer quadrant of the buttock (gluteus maximus) or the mid-lateral thigh. Injections may be given to specific patients with well-developed deltoid muscles; however, the lower and mid-third of the upper arm should be avoided.
-A total dose of 120 grams over the course of therapy should not be exceeded.

Uses:
-As a fourth drug (in a regimen containing isoniazid, rifampin, and pyrazinamide) for the initial treatment of tuberculosis
-Treatment of tuberculosis when isoniazid, rifampin, and/or pyrazinamide is contraindicated because of toxicity or intolerance

American Thoracic Society (ATS), US Centers for Disease Control and Prevention (US CDC), and Infectious Diseases Society of America (IDSA) Recommendations:
15 mg/kg IM or IV once a day OR 25 mg IM or IV 3 times a week

Comment: Patients with renal dysfunction and/or those who are older may require 15 mg/kg given 3 times a week.

Use: Second-line treatment of drug-susceptible tuberculosis caused by susceptible organisms

US Department of Health and Human Services (US HHS), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), and US CDC Recommendations:
15 mg/kg IM or IV every 24 hours OR 25 mg/kg IM or IV 3 times a week

Comment: Doses should be adjusted based on serum concentrations.

Uses:
-Treatment of drug-resistant tuberculosis
-Alternative therapy for active tuberculosis

Usual Adult Dose for Tularemia

1 to 2 grams IM per day, given in divided doses
-Duration of therapy: 7 to 14 days

Comment: This drug should be given until the patient is afebrile for 5 to 7 days.

Use: Treatment of moderate to severe tularemia caused by susceptible strains of Francisella tularensis

IDSA Recommendations:
15 mg/kg IM every 12 hours
Maximum dose: 2 grams/day
Duration of therapy: Up to 14 days

Comment: Due to health risks posed to laboratory personnel, the laboratory should be notified when tularemia is suspected.

Use: Treatment of severe tularemia caused by F tularensis

Usual Adult Dose for Plague

1 gram IM 2 times a day
-Duration of therapy: At least 10 days

Use: Treatment of moderate to severe plague caused by susceptible strains of Pasteurella pestis

IDSA Recommendations:
15 mg/kg IM every 12 hours
-Duration of therapy: 10 to 14 days

Use: Treatment of bubonic plague caused by Yersinia pestis

Usual Adult Dose for Endocarditis

Streptococcal endocarditis:
-Week 1: 1 gram IM 2 times a day
-Week 2: 500 mg IM 2 times a day
-Duration of therapy: 2 weeks

Enterococcal endocarditis:
-Weeks 1 to 2: 1 gram IM 2 times a day
-Weeks 3 to 6: 500 mg IM 2 times a day
-Duration of therapy: 6 weeks

Comment: Discontinuation should be considered in patients who develop ototoxicity during treatment.

Uses:
-Concomitantly with penicillin for the treatment of moderate to severe endocarditis caused by susceptible strains of Streptococcus viridans and Enterococcus faecalis
-Concomitantly with another antibacterial agent for the treatment of moderate to severe endocarditis caused by susceptible strains of Haemophilus influenzae

American Heart Association (AHA) and IDSA Recommendations:
Enterococcal endocarditis: 15 mg/kg IM or IV per day, given in 2 equally divided doses PLUS penicillin G OR ampicillin
-Duration of therapy: 4 to 6 weeks

Uses:
-Treatment of endocarditis involving a native or prosthetic valve or other prosthetic material resulting from Enterococcus species
-Alternative treatment of endocarditis for streptomycin susceptible/gentamicin resistant strains

Usual Adult Dose for Brucellosis

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Use: Treatment of moderate to severe Brucella caused by susceptible strains

WHO Recommendations:
1 gram IM once a day PLUS tetracycline or doxycycline
-Duration of therapy: 2 to 3 weeks

Comment: Treatment with tetracycline or doxycycline should continue for a total of 6 weeks.

Use: Second-line treatment of uncomplicated moderate to severe brucellosis

Usual Adult Dose for Bacteremia

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Chancroid

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Granuloma Inguinale

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Meningitis

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Pneumonia

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Upper Respiratory Tract Infection

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Urinary Tract Infection

1 to 2 grams IM every 6 to 12 hours
-Maximum dose: 2 grams/day

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of Calymmatobacterium granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Haemophilus ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Klebsiella pneumonia
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of Escherichia coli, Proteus species, Aerobacter aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Adult Dose for Mycobacterium avium-intracellulare - Treatment

ATS and IDSA Recommendations:
Severe, extensive (multilobar) fibro cavitary disease OR previously treated disease: 25 mg/kg IV 3 times a week
-Duration of therapy: 2 to 3 months

Nodular/bronchiectatic disease: 8 to 10 mg/kg IM or IV 2 to 3 times a week
Maximum dose: 500 mg/dose (patients older than 50 years)
Duration of therapy: At least 2 months (extensive disease)

Comments:
-A longer duration of therapy may be used in patients with very extensive disease and/or in those who cannot tolerate other agents.
-Some experts prefer amikacin to this drug due to a perceived difference in the severity of vestibular toxicity between the 2 drugs.

Uses:
-Initial regimen for fibrocavitary or severe nodular/bronchiectatic Mycobacterium avium complex (MAC) lung disease
-Preferred treatment with clarithromycin and rifabutin of disseminated MAC disease in HIV-infected patients
-Alternative treatment (with azithromycin and rifabutin) of disseminated MAC disease in HIV-infected patients

US HHS, NIH, HRSA, and US CDC Recommendations:
1 gram IM or IV once a day PLUS ethambutol AND clarithromycin or azithromycin
-Duration of therapy: At least 12 months

Comment: Treatment may be discontinued in patients without signs/symptoms of MAC disease AND sustained (greater than 6 months) CD4 counts greater than 100 cells/mcL in response to antiretroviral therapy.

Use: Alternative additional treatment for disseminated MAC disease in HIV-infected patients with advanced immunosuppression (CD4 counts less than 50 cells/mcL), high mycobacterial loads (greater than log CFU/mL or blood), or in the absence of effective antiretroviral therapy

Usual Adult Dose for Mycobacterium kansasii

ATS and IDSA Recommendations:
Rifampin-resistant infections: 1 gram IM or IV 2 times a week

Comments:
-Treatment should continue for at least 12 months after the patient's sputum is culture-negative.
-This drug should be given as part of a three-drug regimen in accordance with standard treatment protocols.
-Regular sputum testing for mycobacteria is recommended during therapy.

Use: Adjunctive treatment of rifampin-resistant Mycobacterium kansasii disease

Usual Geriatric Dose for Endocarditis

60 years and older:
Streptococcal endocarditis: 500 mg IM 2 times a day
-Duration of therapy: 2 weeks

Enterococcal endocarditis:
-Weeks 1 to 2: 1 gram IM 2 times a day
-Weeks 3 to 6: 500 mg IM 2 times a day
-Duration of therapy: 6 weeks

Comment: Discontinuation should be considered in patients who develop ototoxicity during treatment.

Use: Concomitantly with penicillin for the treatment of moderate to severe endocarditis caused by susceptible strains of S viridans and E faecalis

Usual Geriatric Dose for Tuberculosis - Active

60 years and older:
Doses should be adjusted due to an increased risk of toxicity.

ATS, US CDC, and IDSA Recommendations:
15 mg/kg IM or IV once a day OR 15 to 25 mg IM or IV 3 times a week

Comment: Patients with renal dysfunction and/or those who are older may require 15 mg/kg given 3 times a week.

Use: Second-line treatment of drug-susceptible tuberculosis caused by susceptible organisms

Usual Pediatric Dose for Tuberculosis - Active

Infants and children:
Daily dosing: 20 to 40 mg/kg IM once a day
-Maximum dose: 1 gram/day

Intermittent dosing: 25 to 30 mg/kg IM 2 to 3 times a week
-Maximum dose: 1.5 grams/dose

Duration of therapy: At least 1 year

Comments:
-Infant and small children should be given doses into the periphery of the upper outer quadrant of the buttock (gluteus maximus), and children may be given doses into the mid-lateral muscles of the thigh. Injections may be given to older children with well-developed deltoid muscles; however, the lower and mid-third of the upper arm should be avoided.
-A total dose of 120 grams over the course of therapy should not be exceeded.

Uses:
-As a fourth drug (in a regimen containing isoniazid, rifampin, and pyrazinamide) for the initial treatment of tuberculosis
-Treatment of tuberculosis when isoniazid, rifampin, and/or pyrazinamide is contraindicated because of toxicity or intolerance

ATS, US CDC, and IDSA Recommendations:
Children: 15 to 20 mg/kg IM or IV once a day OR 25 to 30 mg/kg IM or IV 2 times a week

Comment: Patients with renal dysfunction may require 15 mg/kg given 3 times a week.

Use: Second-line treatment of drug-susceptible tuberculosis caused by susceptible organisms

US HHS, NIH, HRSA, and US CDC Recommendations:
Children: 20 to 40 mg/kg IM once a day
Maximum dose: 1 g/day
Duration of therapy: 2 months

Use: First choice for the treatment of drug-susceptible tuberculosis meningitis in HIV-infected patients

Usual Pediatric Dose for Pneumonia

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Use: Treatment of moderate to severe pneumonia not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of K pneumoniae

IDSA and ATS Recommendations:
Duration of therapy: At least 5 days

Comments:
-This drug should be given with an antipseudomonal beta-lactam antibiotic or cipro-/levofloxacin when treating infections caused by Pseudomonas aeruginosa.
-Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
-Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Use: Preferred adjunctive treatment of community-acquired pneumonia caused by P aeruginosa

Usual Pediatric Dose for Brucellosis

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Use: Treatment of moderate to severe Brucella caused by susceptible strains

WHO Recommendations:
8 years and older: 1 gram IM once a day PLUS tetracycline or doxycycline
-Duration of therapy: 2 to 3 weeks

Comment: Treatment with tetracycline or doxycycline should continue for a total of 6 weeks.

Use: Treatment of uncomplicated brucellosis

Usual Pediatric Dose for Bacteremia

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Chancroid

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Granuloma Inguinale

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Meningitis

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Upper Respiratory Tract Infection

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Urinary Tract Infection

Children: 20 to 40 mg/kg IM every 6 to 12 hours

Uses:
-Treatment of moderate to severe donovanosis and/or granuloma inguinale not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of C granulomatis
-Treatment of moderate to severe chancroid not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of H ducreyi
-Concomitantly with another antibiotic for the treatment of moderate to severe respiratory or meningeal infections not amenable to therapy with less potentially toxic agents which are caused by susceptible strains of H influenzae
-Concomitantly with another antibiotic for the treatment of moderate to severe urinary tract infections not amenable to therapy with less potentially toxic agents which is caused by susceptible strains of E coli, Proteus species, A aerogenes, K pneumoniae, and E faecalis
-Concomitantly with another antibiotic for the treatment of moderate to gram-negative bacillary bacteremia not amenable to therapy with less potentially toxic agents

Usual Pediatric Dose for Tularemia

IDSA and ATS Recommendations:
Children: 15 mg/kg IM every 12 hours
Maximum dose: 2 grams/day
Duration of therapy: Up to 14 days

Comments:
-Due to health risks posed to laboratory personnel, the laboratory should be notified when tularemia is suspected.
-Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
-Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Uses:
-Treatment of severe tularemia caused by F tularensis
-Alternative treatment of community-acquired pneumonia caused by F tularensis

Usual Pediatric Dose for Plague

IDSA Recommendations:
Children: 15 mg/kg IM every 12 hours
-Duration of therapy: 10 to 14 days

Comments:
-Treatment with this drug is preferred in patients with recent oral treatment with a fluoroquinolone.
-Patients should be afebrile for at least 48 to 72 hours before discontinuing treatment.

Uses:
-Treatment of bubonic plague caused by Y pestis
-Preferred adjunctive treatment of community-acquired pneumonia caused by Y pestis

Renal Dose Adjustments

Data not available

Renal irritation: Alkalization of the urine may minimize/prevent renal irritation in patients requiring prolonged treatment.

ATS, US CDC, and IDSA Recommendations:
CrCl less than 30 mL/min: 15 mg/kg IM or IV 3 times a week

US HHS, NIH, HRSA, and US CDC Recommendations:
Use with caution.

AHA and IDSA Recommendations:
CrCl less than 50 mL/min: Not recommended. Double-beta lactam regimens should be considered.

Liver Dose Adjustments

Data not available

ATS, US CDC, and IDSA Recommendations:
Severe, unstable liver disease: Some experts state that use should be avoided.

Dose Adjustments

Therapeutic drug monitoring/range:
-Peak levels: 20 to 25 mcg/mL (renal dysfunction)

AHA and IDSA Recommendations:
Endocarditis Therapeutic drug monitoring/range:
-Peak (1-hour serum concentration): 20 to 35 mcg/mL
-Trough: Less than 10 mcg/mL

Precautions

US BOXED WARNINGS:
NEUROTOXICITY:
-The risk of severe neurotoxic reactions is sharply increased in patients with impaired renal function or pre-renal azotemia. These include disturbances of vestibular and cochlear function, optic nerve dysfunction, peripheral neuritis, arachnoiditis, and encephalopathy may also occur.
-The incidence of clinically detectable, irreversible vestibular damage is particularly high in patients treated with this drug.
-The neurotoxicity of this drug can result in respiratory paralysis from neuromuscular blockage, especially when the drug is given soon after the use of anesthesia or muscle relaxants.

MONITORING:
-Renal function should be monitored carefully; patients with renal impairment and/or nitrogen retention should receive reduced doses.
-The peak serum concentration in individuals with kidney damage should not exceed 20 to 25 mcg/mL.

CONCURRENT THERAPY:
-The concurrent or sequential use of other neurotoxic and/or nephrotoxic drugs with this drug, including neomycin, kanamycin, gentamycin, cephaloridine, paromomycin, viomycin, polymyxin B, colistin, tobramycin, and cyclosporine should be avoided.

PARENTERAL FORMS:
-The administration of this drug in parenteral form should be reserved for patients where adequate laboratory and audiometric testing facilities are available during therapy.

NARROW THERAPEUTIC INDEX:
-This drug should be considered a narrow therapeutic index (NTI) drug as small differences in dose or blood concentrations may lead to serious therapeutic failures or adverse drug reactions.
Recommendations:
-Generic substitution should be done cautiously, if at all, as current bioequivalence standards are generally insufficient for NTI drugs.
-Additional and/or more frequent monitoring should be done to ensure receipt of an effective dose while avoiding unnecessary toxicities.

CONTRAINDICATIONS:
-Hypersensitivity to the active component, other aminoglycosides, or any of the ingredients

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

ATS, US CDC, and IDSA Recommendations:
Hemodialysis: 15 mg/kg IM or IV 3 times a week
Peritoneal dialysis: Data not available

Other Comments

Administration advice:
-Aspiration should be performed with each administration to avoid injection into a blood vessel.
-Injections should be administered within the body of a relatively large muscle, and the site should be alternated.
-Deltoid administration should be limited to specific older children and adults with well-developed deltoid muscles, and precautions should be used to avoid radial nerve injury; injection into the lower and middle-third of the upper arm should be avoided.

Storage requirements:
-Dry powder vials: Protect from light.
-Once reconstituted: Protect from light; may be stored at room temperature (15 to 30C) for up to 1 week.

Reconstitution/preparation techniques:
-The manufacturer product information should be consulted.

General:
-Limitation of use: This drug should only be used to treat/prevent infections proven or strongly suspected to be caused by bacteria.

Monitoring:
-Infections: Signs/symptoms of worsening infection and Clostridium difficile
-Other: Serial audiograms in patients old enough to be tested, especially those at high-risk of ototoxicity; toxic signs/symptoms, especially in patients with severe/fulminating infections
-Renal: Renal function (e.g., blood urea nitrogen, serum creatinine, creatinine clearance) prior to starting treatment and daily thereafter

Patient advice:
-Advise patients to speak to their healthcare provider if they become pregnant, intend to become pregnant, or are breastfeeding.
-Patients should be told to report any unusual or severe side effects, including signs/symptoms of ototoxicity and nephrotoxicity.
-Patients should be instructed to report signs/symptoms of C difficile infection (e.g., watery/bloody stools, stomach cramps, fever), for up to 2 months after stopping treatment.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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