Streptomycin

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Streptomycin
Black Box Warning
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adeel Jamil, M.D. [2]

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Black Box Warning

WARNING
See full prescribing information for complete Boxed Warning.
* 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 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 sulfate, 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.

Overview

Streptomycin is an aminoglycosides and antitubercular antibiotic that is FDA approved for the treatment of Mycobacterium tuberculosis and Non-tuberculosis infections like plague, tularemia, Brucella, donovanosis, granuloma inguinale, chancroid, H. influenzae (in respiratory, endocardial, and meningeal infections-concomitantly with another antibacterial agent), K. pneumoniae pneumonia (concomitantly with another antibacterial agent), E.coli, Proteus, A. aerogenes, K. pneumoniae, and Enterococcus faecalis in urinary tract infections. Streptococcus viridans, Enterococcus faecalis (in endocardial infections -concomitantly with penicillin), Gram-negative bacillary bacteremia (concomitantly with another antibacterial agent). There is a Black Box Warning for this drug as shown here. Common adverse reactions include vestibular ototoxicity, nausea, vomiting, vertigo, paresthesia of face, rash, fever, urticaria, angioneurotic edema and eosinophilia..

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

  • Streptomycin is indicated for the treatment of individuals with moderate to severe infections caused by susceptibile strains of microorganisms in the specific conditions listed below:
Mycobacterium Tuberculosis
  • The Advisory Council for the Elimination of tuberculosis, the American Thoracic Society, and the Center for Disease Control recommend that either streptomycin or ethambutol be added as a fourth drug in a regimen containing isoniazid (INH), rifampin and pyrazinamide for initial treatment of tuberculosis unless the likelihood of INH or rifampin resistance is very low. The need for a fourth drug should be reassessed when the results of susceptibility testing are known. In the past when the national rate of primary drug resistance to isoniazid was known to be less than 4% and was either stable or declining, therapy with two and three drug regimens was considered adequate. If community rates of INH resistance are currently less than 4%, an initial treatment regimen with less than four drugs may be considered.
  • Streptomycin is also indicated for therapy of tuberculosis when one or more of the above drugs is contraindicated because of toxicity or intolerance. The management of tuberculosis has become more complex as a consequence of increasing rates of drug resistance and concomitant HIV infection. Additional consultation from experts in the treatment of tuberculosis may be desirable in those settings.
Non-Tuberculosis infections
  • The use of streptomycin should be limited to the treatment of infections caused by bacteria which have been shown to be susceptible to the antibacterial effects of streptomycin and which are not amenable to therapy with less potentially toxic agents.
  • To reduce the development of drug-resistant bacteria and maintain the effectiveness of streptomycin and other antibacterial drugs, streptomycin 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 antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Dosing Information
  • Injection sites should be alternated. As higher doses or more prolonged therapy with streptomycin may be indicated for more severe or fulminating infections (endocarditis, meningitis, etc.), the physician should always take adequate measures to be immediately aware of any toxic signs or symptoms occurring in the patient as a result of streptomycin therapy.
  • The standard regimen for the treatment of drug susceptible tuberculosis has been two months of INH, rifampin and pyrazinamide followed by four months of INH and rifampin (patients with concomitant infection with tuberculosis and HIV may require treatment for a longer period). When streptomycin is added to this regimen because of suspected or proven drug resistance, the recommended dosing for streptomycin is as follows:
This image is provided by the National Library of Medicine.
  • Streptomycin is usually administered daily as a single intramuscular injection. A total dose of not more than 120 g over the course of therapy should be given unless there are no other therapeutic options. In patients older than 60 years of age the drug should be used at a reduced dosage due to the risk of increased toxicity.
  • Therapy with streptomycin may be terminated when toxic symptoms have appeared, when impending toxicity is feared, when organisms become resistant, or when full treatment effect has been obtained. The total period of drug treatment of tuberculosis is a minimum of 1 year; however, indications for terminating therapy with streptomycin may occur at any time as noted above.
  • One to 2 g daily in divided doses for 7 to 14 days until the patient is afebrile for 5 to 7 days.
  • Two grams of streptomycin daily in two divided doses should be administered intramuscularly. :* A minimum of 10 days of therapy is recommended.
  • CONCOMITANT USE WITH OTHER AGENTS:
  • For adults: 1 to 2 grams in divided doses every six to twelve hours for moderate to severe infections. Doses should generally not exceed 2 grams per day.
  • For children: 20 to 40 mg/kg/day (8 to 20 mg/lb/day) in divided doses every 6 to 12 hours. (Particular care should be taken to avoid excessive dosage in children).
  • The dry lyophillized cake is dissolved by adding Water for Injection USP in an amount to yield the desired concentration as indicated in the following table:
This image is provided by the National Library of Medicine.
  • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Streptomycin in adult patients.

Non–Guideline-Supported Use

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Mycobacterium Tuberculosis
  • Dosing Information
This image is provided by the National Library of Medicine.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Streptomycin sulfate in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Streptomycin sulfate in pediatric patients.

Contraindications

  • A history of clinically significant hypersensitivity to streptomycin is a contraindication to its use. Clinically significant hypersensitivity to other aminoglycosides may contraindicate the use of streptomycin because of the known cross-sensitivity of patients to drugs in this class.

Warnings

WARNING
See full prescribing information for complete Boxed Warning.
* 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 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 sulfate, 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.

Ototoxicity=

Pregnancy
  • Streptomycin can cause fetal harm when administered to a pregnant woman. Because streptomycin readily crosses the placental barrier, caution in use of the drug is important to prevent ototoxicity in the fetus. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.
Clostridium difficile associated diarrhea (CDAD)
  • 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.
PRECAUTIONS
  • General
  • Baseline and periodic caloric stimulation tests and audiometric tests are advisable with extended streptomycin therapy. Tinnitus, roaring noises, or a sense of fullness in the ears indicates need for audiometric examination or termination of streptomycin therapy or both.
  • Care should be taken by individuals handling streptomycin for injection to avoid skin sensitivity reactions. As with all intramuscular preparations, Streptomycin Sulfate Injection should be injected well within the body of a relatively large muscle and care should be taken to minimize the possibility of damage to peripheral nerves.
  • Extreme caution must be exercised in selecting a dosage regimen in the presence of pre-existing renal insufficiency. In severely uremic patients a single dose may produce high blood levels for several days and the cumulative effect may produce ototoxic sequelae. When streptomycin must be given for prolonged periods of time alkalinization of the urine may minimize or prevent renal irritation.
  • As with other antibiotics, use of this drug may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, appropriate therapy should be instituted.

Adverse Reactions

Clinical Trials Experience

  • Vestibular symptoms generally appear early and usually are reversible with early detection and cessation of streptomycin administration. Two to three months after stopping the drug, gross Vestibular symptoms usually disappear, except from the relative inability to walk in total darkness or on very rough terrain.
  • Clinical judgment as to termination of therapy must be exercised when side effects occur.

Postmarketing Experience

There is limited information regarding Postmarketing Experience of Streptomycin sulfate in the drug label.

Drug Interactions

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): D

  • Streptomycin can cause fetal harm when administered to a pregnant woman. Because streptomycin readily crosses the placental barrier, caution in use of the drug is important to prevent ototoxicity in the fetus. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.


Pregnancy Category (AUS):

  • Australian Drug Evaluation Committee (ADEC) Pregnancy Category

There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Streptomycin sulfate in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Streptomycin sulfate during labor and delivery.

Nursing Mothers

  • Because of the potential for serious adverse reactions in nursing infants from streptomycin, 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.

Pediatric Use

There is no FDA guidance on the use of Streptomycin sulfate with respect to pediatric patients.

Geriatic Use

There is no FDA guidance on the use of Streptomycin sulfate with respect to geriatric patients.

Gender

There is no FDA guidance on the use of Streptomycin sulfate with respect to specific gender populations.

Race

There is no FDA guidance on the use of Streptomycin sulfate with respect to specific racial populations.

Renal Impairment

  • 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 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.
  • 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.

Hepatic Impairment

There is no FDA guidance on the use of Streptomycin sulfate in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Streptomycin sulfate in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Streptomycin sulfate in patients who are immunocompromised.

Administration and Monitoring

Administration

Monitoring

Nephrotoxicity
  • 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.
Ototoxicity

IV Compatibility

There is limited information regarding IV Compatibility of Streptomycin sulfate in the drug label.

Overdosage

There is limited information regarding Chronic Overdose of Streptomycin sulfate in the drug label.

Pharmacology

Streptomycin3.png
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Streptomycin
Systematic (IUPAC) name
5-(2,4-diguanidino-
3,5,6-trihydroxy-cyclohexoxy)- 4-[4,5-dihydroxy-6-(hydroxymethyl)
-3-methylamino-tetrahydropyran-2-yl] oxy-3-hydroxy-2-methyl
-tetrahydrofuran-3-carbaldehyde
Identifiers
CAS number 57-92-1
ATC code A07AA04 J01GA01
PubChem 19649
DrugBank DB01082
Chemical data
Formula C21H39N7O12 
Mol. mass 581.574 g/mol
SMILES eMolecules & PubChem
Physical data
Melt. point 12 °C (54 °F)
Pharmacokinetic data
Bioavailability 84% to 88% (est.)[1]
Metabolism  ?
Half life 5 to 6 hours
Excretion Renal
Therapeutic considerations
Pregnancy cat.

D(US)

Legal status

POM(UK) -only(US)

Routes Intramuscular, intravenous

Mechanism of Action

  • Streptomycin sulfate is a bactericidal antibiotic. It acts by interfering with normal protein synthesis.

Structure

  • Streptomycin is a water-soluble aminoglycoside derived from Streptomyces griseus. It is marketed as the sulfate salt of streptomycin. The chemical name of streptomycin sulfate is D-Streptamine, O-2-deoxy-2-(methylamino)-α-L-glucopyranosyl-(1→2)-O-5-deoxy-3-C-formyl-α-L-lyxofuranosyl-(1→4)-N,N1-bis(aminoiminomethyl)-,sulfate (2:3) (salt). The molecular formula for Streptomycin Sulfate is (C21H39N7O12)2 -3H2SO4 and the molecular weight is 1457.41. It has the following structural formula:
This image is provided by the National Library of Medicine.

Pharmacodynamics

Microbiology

  • Streptomycin sulfate is a bactericidal antibiotic. It acts by interfering with normal protein synthesis.
  • Streptomycin has been shown to be active against most strains of the following organisms both in vitro and in clinical infection.

Pharmacokinetics

  • Following intramuscular injection of 1 g of streptomycin as the sulfate, a peak serum level of 25 to 50 mcg/mL is reached within 1 hour, diminishing slowly to about 50 percent after 5 to 6 hours.
  • Appreciable concentrations are found in all organ tissues except the brain. Significant amounts have been found in pleural fluid and tuberculous cavities. Streptomycin passes through the placenta with serum levels in the cord blood similar to maternal levels. Small amounts are excreted in milk, saliva, and sweat.
  • Streptomycin is excreted by glomerular filtration. In patients with normal kidney function, between 29% and 89% of a single 400 mg dose is excreted in the urine within 24 hours. Any reduction of glomerular function results in decreased excretion of the drug and concurrent rise in serum and tissue levels.

Nonclinical Toxicology

There is limited information regarding Nonclinical Toxicology of Streptomycin sulfate in the drug label.

Clinical Studies

There is limited information regarding Clinical Studies of Streptomycin sulfate in the drug label.

How Supplied

  • Streptomycin for Injection USP is available in single vials containing 1 gram NDC 39822-0706-1 packaged as boxes of ten vials NDC 39822-0706-2.

Storage

  • Store dry powder under controlled room temperature 15° to 30°C (59° to 86°F)

Images

Drug Images

Package and Label Display Panel

NDC 39822-0706-1 Streptomycin for Injection, USP 1 gram*/ vial For Intramuscular Use Rx Only 1 Vial X-GEN Pharmaceuticals, Inc.

NDC 39822-0706-2 Streptomycin for Injection, USP 1 gram*/ vial For Intramuscular Use Rx Only 10 Vial carton X-GEN Pharmaceuticals, Inc.

Patient Counseling Information

  • Patients should be counseled that antibacterial drugs including streptomycin should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When streptomycin 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 streptomycin 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.

Precautions with Alcohol

  • Alcohol-Streptomycin sulfate interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Streptomycin Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Streptomycin Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

  1. Zhu M, Burman WJ, Jaresko GS, Berning SE, Jelliffe RW, Peloquin CA. (October 2001). "Population pharmacokinetics of intravenous and intramuscular streptomycin in patients with [[tuberculosis]]". Pharmacotherapy. 21 (9): 1037–1045. PMID 11560193. doi:10.1592/phco.21.13.1037.34625. Retrieved 2010-05-25. 

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