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Streptomycin: Drug information

Streptomycin: Drug information
(For additional information see "Streptomycin: Patient drug information" and see "Streptomycin: Pediatric drug information")

For abbreviations and symbols that may be used in Lexicomp (show table)
ALERT: US Boxed Warning
Toxicity:

The risk of severe neurotoxic reactions is sharply increased in patients with impaired renal function or prerenal azotemia. These include disturbances of vestibular and cochlear function, optic nerve dysfunction, peripheral neuritis, arachnoiditis, and encephalopathy. The incidence of clinically detectable, irreversible vestibular damage is particularly high in patients treated with streptomycin.

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.

The concurrent or sequential use of other neurotoxic and/or nephrotoxic drugs with streptomycin, including neomycin, kanamycin, gentamicin, cephaloridine, paromomycin, viomycin, polymyxin B, colistin, tobramycin, and cyclosporine should be avoided.

The neurotoxicity of streptomycin can result in respiratory paralysis from neuromuscular blockage, especially when the drug is given soon after the use of anesthesia or muscle relaxants.

The administration of streptomycin in parenteral form should be reserved for patients where adequate laboratory and audiometric testing facilities are available during therapy.

Brand Names: Canada
  • Streptomycin
Pharmacologic Category
  • Antibiotic, Aminoglycoside;
  • Antitubercular Agent
Dosing: Adult

Note: Route of administration: Manufacturer’s labeling states for IM administration only; however, IV administration (off-label route) has been described (Morris 1994; Peloquin 1992; Tanoira 2014).

Aminoglycoside dosing weight: For underweight patients (ie, total body weight [TBW] < ideal body weight [IBW]), calculate the dose based on TBW. For nonobese patients (ie, TBW 1 to 1.25 × IBW), calculate the dose based on TBW or IBW. TBW may be preferred in nonobese patients who may have increased volume of distribution (eg, critically ill). For obese patients (ie, TBW > 1.25 × IBW), calculate the dose based on 40% adjusted body weight (IBW + [0.4 × (TBW-IBW)]) (Blackburn 2015; Drew 2020). Therapeutic drug monitoring: Monitoring of serum concentrations is recommended to ensure efficacy and avoid toxicity; confirm availability of rapid streptomycin serum concentrations. Timing and frequency of concentration monitoring is individualized based on dosing and monitoring strategy (AHA [Baddour 2015]; Drew 2020; Park 2015; Zhu 2001).

Usual dosage range: IM, IV: 15 to 30 mg/kg/day or 1 to 2 g daily.

Indication-specific dosing:

Brucellosis: IM, IV: 1 g once daily in combination with doxycycline. Duration depends on extent of disease; streptomycin is usually given for the first 14 to 21 days of therapy, followed by doxycycline monotherapy (Ariza 2007; Bosilkovski 2020; Hasanjani Roushan 2006; Skalsky 2008). Note: Additional agents or other regimens are preferred for neurobrucellosis, endocarditis, and infection in pregnant women (Bosilkovski 2020).

Endocarditis (alternate agent):

Enterococcus spp. (native or prosthetic valve, susceptible to penicillin and streptomycin/resistant to gentamicin): IM, IV: 7.5 mg/kg every 12 hours in combination with ampicillin or penicillin; Duration of therapy: 4 weeks (native valve and symptoms present <3 months); ≥6 weeks (native valve and symptoms present ≥3 months or prosthetic valve). Note: For native valve endocarditis due to ampicillin-susceptible E. faecalis, a combination regimen that does not contain streptomycin is preferred (AHA [Baddour 2015]).

Mycobacterial (nontuberculous) (M. avium complex) infection (off-label use):

Pulmonary disease (severe nodular/bronchiectatic or cavitary disease) (adjunctive agent): IM, IV: 10 to 15 mg/kg once daily or 15 to 25 mg/kg 3 times weekly (ATS/ERS/ESCMID/IDSA [Daley 2020]; Peloquin 2004) or 10 to 15 mg/kg 3 times weekly (Kasperbauer 2020) or 15 mg/kg once daily (usual maximum dose: 1 g) for 1 month then 15 mg/kg 3 times weekly (BTS [Haworth 2017]). Give streptomycin as part of an appropriate combination regimen for the first 2 to 3 months of therapy (ATS/ERS/ESCMID/IDSA [Daley 2020]). Note: For older adults or patients who require >6 months of parenteral therapy, some experts recommend empiric dose reduction (BTS [Haworth 2017]).

Pulmonary disease (cavitary or severe bronchiectatic or acid-fast bacilli smear-positive respiratory samples) or systemic illness in patients with cystic fibrosis (adjunctive agent): IM, IV: 15 mg/kg once daily (maximum: 1 g daily) as part of an appropriate combination regimen (CFF/ECFS [Floto 2016]).

Disseminated disease in patients with HIV with CD4 count <50 cells/mm3, high mycobacterial loads (ie, >2 log colony-forming units/mL of blood), or in the absence of effective antiretroviral therapy (adjunctive agent): IM, IV: 1 g once daily as part of an appropriate combination regimen (HHS [OI adult 2019]).

Plague: IM: 15 mg/kg (maximum dose: 1 g) every 12 hours for 10 days or until the patient is afebrile for at least 2 to 3 days (CDC 2014; WHO 2009).

Tuberculosis (alternative agent): IM, IV: 15 mg/kg once daily or 25 mg/kg 3 times weekly (ATS/CDC/ERS/IDSA [Nahid 2019]; ATS/CDC/IDSA [Nahid 2016]).

Tularemia (alternative agent): IM: 1 g twice daily for ≥10 days depending on severity (CDC 2019; WHO 2007).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Renal Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; however, the following adjustments have been recommended:

Aronoff 2007: Note: Recommendations are based on doses of 1 to 2 g every 6 to 12 hours (1 g once daily for tuberculosis):

CrCl >50 mL/minute: No dosage adjustment necessary.

CrCl 10 to 50 mL/minute: Administer every 24 to 72 hours.

CrCl <10 mL/minute: Administer every 72 to 96 hours.

End-stage renal disease (ESRD):

Intermittent hemodialysis (IHD): One-half the recommended dose administered after hemodialysis on dialysis days. Note: Dosing dependent on the assumption of 3 times weekly complete IHD sessions.

Peritoneal dialysis (PD): Administration via PD fluid: 20 to 40 mg/L (20 to 40 mcg/mL) of PD fluid.

CRRT: Administer every 24 to 72 hours; monitor levels. Note: Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate).

ATS/CDC/IDSA [Nahid 2016]:

Tuberculosis:

CrCl ≥30 mL/minute: No dosage adjustment necessary.

CrCl <30 mL/minute: 15 mg/kg/dose 2 to 3 times weekly.

ESRD on IHD: 15 mg/kg/dose 2 to 3 times weekly. Give after dialysis if given on day of dialysis.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Pediatric

(For additional information see "Streptomycin: Pediatric drug information")

Note: IM route preferred; consider use of IV route if IM therapy not tolerated. Monitor serum drug concentrations.

General dosing, combination therapy for susceptible infection: Infants, Children, and Adolescents:

Manufacturer's labeling: IM: 20 to 40 mg/kg/day in divided doses every 6 to 12 hours; maximum dose: 1,000 mg/dose; maximum daily dose: 2,000 mg/day

Alternate dosing: IM, IV: 20 to 30 mg/kg/day divided every 12 hours; maximum daily dose: 1,000 mg/day (Bradley 2015)

Endocarditis, Enterococcal, resistant to gentamicin: Infants, Children, and Adolescents: IM, IV: 20 to 30 mg/kg/day divided every 12 hours; maximum daily dose: 2,000 mg/day; used in combination with other antibiotics, adjust dose to target concentrations (AHA [Baddour] 2005)

Mycobacterium avium complex, treatment: Limited data available: Adolescents: IM, IV: 1,000 mg once daily as part of combination therapy (HHS [Adult] 2016)

Mycobacterium ulcerans (Buruli ulcers): Limited data available: Infants, Children, and Adolescents: IM: 15 mg/kg once daily; maximum daily dose: 1,000 mg/day; used in combination with rifampin for 8 weeks, or may use this combination for 4 weeks, followed by 4 weeks of rifampin-claithromycin combination therapy (WHO 2012)

Plague: Infants, Children, and Adolescents: IM, IV: 30 mg/kg/day divided every 12 hours for 10 days; maximum daily dose: 2,000 mg/day (Red Book [AAP 2015]; WHO 2009)

Tuberculosis; active infection; treatment (second-line therapy); multidrug-resistant (MDR) or meningitis: Note: Always use as part of a multidrug regimen. Any regimens using less than once daily dosing should administer dosing as directly observed therapy (DOT). Treatment regimens for MDR TB are variable depending upon sensitivity and clinical response. Streptomycin frequency and dosing differs depending on treatment regimen selected; consult current drug-sensitive TB guidelines for detailed information (ATS/CDC/IDSA [Nahid 2016]; Schaaf 2015).

Primary pulmonary disease:

Once daily therapy:

Infants, Children, and Adolescents <15 years weighing ≤40 kg: Note: Suggested expert dosing range is large and variable (Schaaf 2015); IM, IV: 15 to 40 mg/kg/dose once daily; some experts recommend an initial dose range of 15 to 20 mg/kg/dose once daily; maximum daily dose: 1,000 mg/day; monitor serum concentrations (ATS/CDC/IDSA [Nahid 2016]; Schaaf 2015; WHO, 2009a). Note: Some clinicians suggest every 12-hour dosing may be utilized (Berenberg 1951; Bradley 2015).

Children and Adolescents <15 years weighing >40 kg or Adolescents ≥15 years: IM, IV: 15 mg/kg/dose once daily; maximum daily dose: 1,000 mg/day; monitor serum concentrations (ATS/CDC/IDSA [Nahid 2016]; Pérez Tanoira 2014)

Three-times-weekly DOT: Children and Adolescents <15 years weighing >40 kg or Adolescents ≥15 years: IM, IV: 25 mg/kg/dose three times weekly; maximum dose: 1,000 mg/dose (ATS/CDC/IDSA [Nahid 2016]

Twice weekly DOT: Infants, Children, and Adolescents <15 years weighing ≤40 kg: IM, IV: 25 to 30 mg/kg/dose twice weekly; maximum dose: 1,000 mg/dose (ATS/CDC/IDSA [Nahid 2016])

Meningitis (independent of HIV-status): Infants, Children, and Adolescents: Note: Suggested expert dosing range is large and variable (Schaaf 2015): IM, IV: 15 to 40 mg/kg/dose once daily; some experts recommend an initial dose range of 15 to 20 mg/kg/dose once daily; maximum daily dose: 1,000 mg/day; monitor serum concentrations (ATS/CDC/IDSA [Nahid 2016]; DHHS [pediatric] 2013; Red Book [AAP 2015]; Schaaf 2015)

Tularemia: Infants, Children, and Adolescents: IM: 15 mg/kg/dose twice daily for 10 days; maximum daily dose: 2,000 mg/day (WHO 2007)

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Renal Impairment: Pediatric

There are no adjustments provided in the manufacturer's labeling; however, the following adjustments have been recommended (Aronoff 2007):

Infants, Children, and Adolescents: Note: Renally adjusted dose recommendations are based on doses of 20 to 40 mg/kg/day every 24 hours. Monitor serum concentrations.

GFR 30 to 50 mL/minute/1.73 m2: Administer 7.5 mg/kg/dose every 24 hours

GFR 10 to 29 mL/minute/1.73 m2: Administer 7.5 mg/kg/dose every 48 hours

GFR <10 mL/minute/1.73 m2: Administer 7.5 mg/kg/dose every 72 to 96 hours

Intermittent hemodialysis (IHD): Administer 7.5 mg/kg/dose every 72 to 96 hours

Peritoneal dialysis (PD): Administer 7.5 mg/kg/dose every 72 to 96 hours

Continuous renal replacement therapy (CRRT): Administer every 24 hours; monitor levels. Note: Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate).

Dosing: Hepatic Impairment: Pediatric

There are no adjustments provided in the manufacturer's labeling.

Dosing: Geriatric

Dose reductions are recommended by the manufacturer in patients >60 years of age.

M. avium complex disease: IM/IV: 8 to 10 mg/kg 2 to 3 times weekly (maximum dose for >50 years of age: 500 mg) (ATS/IDSA [Griffith 2007]) or 10 mg/kg once daily for the first month followed by 15 mg/kg 3 times weekly (maximum dose for >59 years of age: 750 mg) (BTS [Haworth 2017]).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intramuscular [preservative free]:

Generic: 1 g (1 ea)

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intramuscular:

Generic: 1 g (5 mL)

Administration: Adult

IM: Inject deep IM into large muscle mass; midlateral thigh muscle or upper outer quadrant of buttocks; rotate injection sites.

IV (off-label route): After dilution in admixture, infuse over 30 to 60 minutes (Morris 1994; Peloquin 1992; Tanoira 2014)

Administration: Pediatric

Parenteral:

IM: Inject deep IM into a large muscle mass; rotate injection sites

IV: After further dilution, infuse over 30 to 60 minutes (Morris 1994; Peloquin 1992; Pérez Tanoira 2014)

Use: Labeled Indications

Tuberculosis:

Treatment of tuberculosis, in combination with other appropriate antituberculosis agents, when the primary agents are contraindicated because of toxicity or intolerance.

Nontuberculosis infections:

Treatment of infections caused by susceptible bacteria that are not amenable to therapy with less potentially toxic agents, including sensitive Yersinia pestis (plague); Francisella tularensis (tularemia); Brucella; Klebsiella granulomatis (donovanosis, granuloma inguinale); Haemophilus ducreyi (chancroid); Haemophilus influenzae (in respiratory, endocardial, and meningeal infections, concomitantly with another antibacterial agent); Klebsiella pneumoniae pneumonia (concomitantly with another antibacterial agent); Escherichia coli, Proteus spp., Klebsiella aerogenes (formerly Enterobacter aerogenes), K. pneumoniae, and Enterococcus faecalis in urinary tract infections; Streptococcus viridans; E. faecalis (in endocardial infections, concomitant with penicillin); and gram-negative bacillary bacteremia (concomitant with another antibacterial agent).

Use: Off-Label: Adult

Mycobacterium avium complex infection

Medication Safety Issues
Sound-alike/look-alike issues:

Streptomycin may be confused with streptozocin

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Frequency not defined.

Cardiovascular: Hypotension

Central nervous system: Drug fever, facial paresthesia, headache, neurotoxicity

Dermatologic: Exfoliative dermatitis, skin rash, urticaria

Gastrointestinal: Nausea, vomiting

Genitourinary: Azotemia, nephrotoxicity

Hematologic & oncologic: Eosinophilia, hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia

Hypersensitivity: Anaphylaxis, angioedema

Neuromuscular & skeletal: Arthralgia, tremor, weakness

Ophthalmic: Amblyopia

Otic: Auditory ototoxicity, vestibular ototoxicity

Respiratory: Dyspnea

<1%, postmarketing, and/or case reports: DRESS syndrome (drug reaction with eosinophilia and systemic symptoms), toxic epidermal necrolysis

Contraindications

Hypersensitivity to streptomycin, other aminoglycosides, or any component of the formulation

Warnings/Precautions

Concerns related to adverse effects:

• Neuromuscular blockade and respiratory paralysis: [US Boxed Warning]: May cause neuromuscular blockade and respiratory paralysis; especially when given soon after anesthesia or muscle relaxants.

• Neurotoxicity: [US Boxed Warning]: May cause neurotoxicity, including disturbances of vestibular and cochlear function, optic nerve dysfunction, peripheral neuritis, arachnoiditis, and encephalopathy; usual risk factors include pre-existing renal impairment, concomitant neuro-/nephrotoxic medications. Ototoxicity is proportional to the amount of drug given and the duration of treatment. Tinnitus or vertigo may be indications of vestibular injury and impending bilateral irreversible damage. Baseline and periodic caloric stimulation and audiometric tests are recommended with prolonged therapy. Discontinue treatment if signs of ototoxicity occur.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Hearing impairment: Use with caution in patients with pre-existing vertigo, tinnitus, or hearing loss.

• Neuromuscular disorders: Use with caution in patients with neuromuscular disorders, including myasthenia gravis.

• Renal impairment: [US Boxed Warning]: May cause nephrotoxicity. Use with caution in patients with renal impairment; dose adjustment necessary in patients with renal impairment and/or nitrogen retention. Monitor renal function closely; peak serum concentrations should not surpass 20 to 25 mcg/mL in patients with renal impairment.

Concurrent drug therapy issues:

• Neurotoxic and/or nephrotoxic drugs: [US Boxed Warning]: Avoid concomitant or sequential use with other neurotoxic and/or nephrotoxic drugs (eg, neomycin, kanamycin, gentamicin, paromomycin, polymyxin B, colistin, tobramycin, cyclosporine).

Dosage form specific issues:

• Sulfite sensitivity: Some formulations may contain sodium metabisulfite; may cause allergic reactions including anaphylaxis or asthma exacerbations (some life-threatening) in susceptible patients.

Other warnings/precautions:

• Appropriate use: [US Boxed Warning]: Parenteral form should be used only where appropriate audiometric and laboratory testing facilities are available. IM injections should be administered in a large muscle well within the body to avoid peripheral nerve damage and local skin reactions.

Metabolism/Transport Effects

None known.

Drug Interactions

Amphotericin B: May enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy

Arbekacin: May enhance the nephrotoxic effect of Aminoglycosides. Arbekacin may enhance the ototoxic effect of Aminoglycosides. Risk C: Monitor therapy

Ataluren: May enhance the adverse/toxic effect of Aminoglycosides. Specifically, an increased risk of nephrotoxicity may occur with the concomitant use of ataluren and aminoglycosides. Risk X: Avoid combination

Bacitracin (Systemic): Streptomycin may enhance the nephrotoxic effect of Bacitracin (Systemic). Risk X: Avoid combination

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

Bisphosphonate Derivatives: Aminoglycosides may enhance the hypocalcemic effect of Bisphosphonate Derivatives. Risk C: Monitor therapy

Botulinum Toxin-Containing Products: Aminoglycosides may enhance the neuromuscular-blocking effect of Botulinum Toxin-Containing Products. Risk C: Monitor therapy

Capreomycin: May enhance the neuromuscular-blocking effect of Aminoglycosides. Risk C: Monitor therapy

CARBOplatin: Aminoglycosides may enhance the ototoxic effect of CARBOplatin. Especially with higher doses of carboplatin. Risk C: Monitor therapy

Cephalosporins: May enhance the nephrotoxic effect of Aminoglycosides. Cephalosporins may decrease the serum concentration of Aminoglycosides. Risk C: Monitor therapy

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

CISplatin: May enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy

Colistimethate: Aminoglycosides may enhance the nephrotoxic effect of Colistimethate. Aminoglycosides may enhance the neuromuscular-blocking effect of Colistimethate. Management: Avoid coadministration of colistimethate and aminoglycosides whenever possible due to the risk of nephrotoxicity and neuromuscular blockade. If coadministration cannot be avoided, monitor renal and neuromuscular function. Risk D: Consider therapy modification

CycloSPORINE (Systemic): Aminoglycosides may enhance the nephrotoxic effect of CycloSPORINE (Systemic). Risk C: Monitor therapy

Distigmine: Aminoglycosides may diminish the therapeutic effect of Distigmine. Risk C: Monitor therapy

Foscarnet: May enhance the nephrotoxic effect of Aminoglycosides. Risk X: Avoid combination

Kanamycin: Aminoglycosides may enhance the adverse/toxic effect of Kanamycin. Management: Coadministration of kanamycin and other potentially ototoxic or nephrotoxic agents, such as aminoglycosides, is not recommended. If this combination must be used, monitor carefully neurotoxic, ototoxic, or nephrotoxic effects. Risk D: Consider therapy modification

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

Loop Diuretics: May enhance the adverse/toxic effect of Aminoglycosides. Specifically, nephrotoxicity and ototoxicity. Risk C: Monitor therapy

Mannitol (Systemic): May enhance the nephrotoxic effect of Aminoglycosides. Risk X: Avoid combination

Mecamylamine: Aminoglycosides may enhance the neuromuscular-blocking effect of Mecamylamine. Risk X: Avoid combination

Methoxyflurane: Aminoglycosides may enhance the nephrotoxic effect of Methoxyflurane. Risk X: Avoid combination

Neuromuscular-Blocking Agents: Aminoglycosides may enhance the therapeutic effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May decrease the excretion of Aminoglycosides. Data only in premature infants. Risk C: Monitor therapy

Oxatomide: May enhance the ototoxic effect of Aminoglycosides. Risk C: Monitor therapy

Penicillins: May decrease the serum concentration of Aminoglycosides. Primarily associated with extended spectrum penicillins, and patients with renal dysfunction. Risk C: Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Tacrolimus (Systemic): Aminoglycosides may enhance the nephrotoxic effect of Tacrolimus (Systemic). Risk C: Monitor therapy

Tenofovir Products: Aminoglycosides may increase the serum concentration of Tenofovir Products. Tenofovir Products may increase the serum concentration of Aminoglycosides. Risk C: Monitor therapy

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification

Vancomycin: May enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy

Reproductive Considerations

Evaluate pregnancy status prior to treatment of multidrug resistant tuberculosis in females of reproductive potential. Females of reproductive potential should use effective contraception during treatment for multidrug resistant tuberculosis (Esmail 2018).

Pregnancy Considerations

Streptomycin crosses the placenta.

Streptomycin may cause fetal harm if administered to a pregnant patient. There are multiple reports of total irreversible bilateral congenital deafness in children whose mothers received streptomycin during pregnancy.

Streptomycin is approved for the treatment of tuberculosis. Active tuberculosis infection is associated with adverse fetal outcomes including intrauterine growth restriction, low birth weight, preterm birth, and perinatal death (Esmail 2018; Miele 2020) as well as adverse maternal outcomes, including increased risks for anemia and cesarean delivery. Placental transmission may rarely occur with active maternal disease (Miele 2020). The treatment of multidrug resistant tuberculosis in pregnant patients should be individualized; evidence to support a specific regimen is not available (ATS/CDC/ERS/IDSA [Nahid 2019]; WHO 2020). When second-line agents are needed for the treatment of multidrug resistant tuberculosis during pregnancy, aminoglycosides should be avoided when alternative agents are effective (ATS/CDC/ERS/IDSA [Nahid 2019]). Streptomycin is not the preferred agent when an aminoglycoside is required for the treatment of tuberculosis during pregnancy (HHS [OI adult 2019]).

Streptomycin is approved for the treatment of Yersinia pestis (plague) infection. Untreated infection has a high rate of maternal death and fetal loss. When an aminoglycoside is needed for the treatment of Y. pestis during pregnancy, an agent other than streptomycin is preferred (Fleck-Derderian 2020; WHO 2009; Yu 2020).

Breast-Feeding Considerations

Streptomycin is present in breast milk.

Aminoglycosides have poor oral bioavailability (Edson 1991), which may limit systemic absorption via breast milk. Streptomycin is considered compatible with breastfeeding. In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora. Monitor infants for GI disturbances, such as thrush and diarrhea (WHO 2002). Patients with multidrug resistant tuberculosis and a sputum smear-positive test should avoid breastfeeding when possible (Esmail 2018).

Monitoring Parameters

Baseline and periodic hearing tests (audiograms), clinical assessment for vertigo and tinnitus, BUN, creatinine, serum electrolytes; serum drug concentrations should be monitored in all patients (ATS/CDC/ERS/IDSA [Nahid 2019]).

Reference Range

Therapeutic:

Peak: Daily dosing: 20 to 35 mcg/mL (35 to 45 mcg/mL for mycobacterial disease); Three times weekly dosing: 65 to 80 mcg/mL (AHA [Baddour 2015]; ATS/ERS/ESCMID/IDSA [Daley 2020]; BTS [Haworth 2017]; CFF/ECFS [Floto 2016]; Edson 1991; Peloquin 2004; Zhu 2001).

Trough: <5 mcg/mL (AHA [Baddour 2015]; BTS [Haworth 2017]; CFF/ECFS [Floto 2016]; Edson 1991; Zhu 2001).

Supratherapeutic: Trough: >10 mcg/mL.

Mechanism of Action

Inhibits bacterial protein synthesis by binding directly to the 30S ribosomal subunits causing faulty peptide sequence to form in the protein chain

Pharmacodynamics and Pharmacokinetics

Absorption: Oral: Poorly absorbed; IM: Well absorbed

Distribution: Distributes into most body tissues and fluids except the brain; small amounts enter the CSF only with inflamed meninges

Protein binding: 34%

Half-life elimination: Newborns: 4 to 10 hours; Adults: ~2 to 4.7 hours; prolonged with renal impairment

Time to peak: IM: Within 1 to 2 hours

Excretion: Urine (29% to 89% as unchanged drug); small amount (1%) excreted in bile, saliva, sweat, and tears

Pricing: US

Solution (reconstituted) (Streptomycin Sulfate Intramuscular)

1 g (per each): $93.75

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Ambistryn-S (IN);
  • Bio-Strep (ZA);
  • Estrepto-Monaxin (MX);
  • Solustrep (ZA);
  • Strepiovit (LK);
  • Strepto (TH);
  • Strepto-Hefa (DE);
  • Streptocin (MY);
  • Streptomycinum (PL);
  • Streptosol (ZW);
  • Stretopen (BD)


For country abbreviations used in Lexicomp (show table)

REFERENCES

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  2. Ad Hoc Committee of the Scientific Assembly on Microbiology, Tuberculosis, and Pulmonary Infections. Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children. Clin Infect Dis. 1995;21:9-27.
  3. American Academy of Pediatrics (AAP). Streptomycin. In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. American Academy of Pediatrics; 2015.
  4. American Academy of Pediatrics Committee on Infectious Diseases. Chemotherapy for tuberculosis in infants and children. Pediatrics. 1992;89(1):161-5. [PubMed 1728006]
  5. American Thoracic Society (ATS); CDC; Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep. 2003;52(RR-11):1-77. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm [PubMed 12836625]
  6. Ariza J, Bosilkovski M, Cascio A, et al. Perspectives for the treatment of brucellosis in the 21st century: the Ioannina recommendations. PLoS Med. 2007;4(12):e317. doi:10.1371/journal.pmed.0040317 [PubMed 18162038]
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  8. Arguedas AG, Wehrle PP. New Concepts for Antimicrobial Use in Central Nervous System Infections. Semin Pediatr Infect Dis. 1991;2(1):36-42.
  9. Baddour LM, Wilson WR, Bayer AS, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435-1486. doi:10.1161/CIR.0000000000000296 [PubMed 26373316]
  10. Balyan FR, Taibah A, De Donato G, et al. Titration streptomycin therapy in Meniere's disease: long-term results. Otolaryngol Head Neck Surg. 1998;118(2):261-266. doi:10.1016/S0194-5998(98)80028-4 [PubMed 9482564]
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