Streptomycin

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Drugs>Antimicrobial Agents>

Streptomycin

Paul A. Pham, Pharm.D. and John G. Bartlett, M.D.
08-04-2009

Zambia Specific Information

Available formulation in Zambia (Powder for injection): 1 g (as sulfate) vial.
Addition of streptomycin to EZRH (ethambutol, pyrazinamide, rifampin, and isoniazid) recommended during first 2 months in TB-smear positive re-treatment cases (e.g. treatment failure, treatment after default, smear positive relapse).
Brucellosis (especially with for osteo-articular or cardiac involvement): streptomycin 1gm IM q24h x 3 weeks PLUS doxycycline 100 mg PO q12h x 6 wks.
Streptomycin should be avoided in pregnant patients, patients with impaired renal function, and elderly (>65 years old).

Zambia Information Author: Paul A. Pham Pharm.D.

INDICATIONS

FDA

Mycobacterium tuberculosis (2nd line)
Yersinia pestis (plague)
Francisella tularensis (tularemia)
Brucella infection
Klebsiella granulomatis (Donovanosis, granuloma inguinale),
Haemophilus ducreyi(chancroid);Haemophilus influenzae
Urinary tract infections(not a first-line agent)
Endocarditis caused by Streptococcus viridans(used in combination with PCN), Enterococcus faecalis (use with ampicillin)
Gram-negative bacillary bacteremia (concomitantly with another antibacterial agent) 11) K. pneumoniae pneumonia

FORMS

brand name	generic	Mfg	brand forms	cost*
Streptomycin	Streptomycin	~X-Gen	IM vial 1g	$14.65

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

TB: 15mg/kg/d (max 1gm) IM once daily.
TB DOT regimen:25-30mg/kg IM 2-3x/wk.
Enterococcal endocarditis (synergy with ampicillin if resistant to gentamicin and sensitive to streptomycin): 7.5mg/kg IM q12h (max dose per day is 2gm with a target peak 1hour after IM dose of 20mcg/ml and trough <10 mcg/mL).

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

TB: 15 mg/kg q24-72h (monitor serum concentrations; target trough <10 mcg/mL); Synergy for enterococcal endocarditis: 7.5 mg/kg q12-24h (monitor serum concentrations; target trough <10 mcg/mL).

DOSING FOR GLOMERULAR FILTRATION OF 10-50

TB: 15mg/kg q72-96h (monitor serum concentrations; target trough <10 mcg/mL). Synergy for enterococcal endocarditis: 7.5 mg/kg q24-72h (monitor serum concentrations; target trough <10 mcg/mL).

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

TB and synergy for Enterococcal endocarditis: 7.5mg/kg q72-96h (monitor serum concentrations; target trough <10 mcg/mL).

DOSING IN HEMODIALYSIS

TB: 12-15mg/kg 2-3x/week (monitor serum concentrations; target trough <10 mcg/mL). Synergy for enterococcal endocarditis: 7.5 mg/kg q96h (monitor serum concentrations; target trough <10 mcg/mL).

DOSING IN PERITONEAL DIALYSIS

20-40mg/Liter of dialysate per day (monitor serum concentrations closely; target trough <10 mcg/mL).

DOSING IN HEMOFILTRATION

15 mg/kg q24 to 72h (dose adjust based on serum concentrations; target trough <10 mcg/mL).

ADVERSE DRUG REACTIONS

OCCASIONAL

Renal failure
Otological/vestibular damage. The most ototoxic of all aminoglycosides. Peak should not exceed 20-25 mcg/mL.

RARE

Optic nerve dysfunction
Peripheral neuritis
Arachnoiditis
Neuromuscular blockade
Encephalopathy

DRUG INTERACTIONS

Loop diuretic (especially w/ ethacrynic acid): additive ototoxicity. Avoid co-administration with streptomycin.
Nephrotoxic agents (e.g., cidofovir, foscarnet, pentamidine, ampho B): may increase risk of nephrotoxicity. Avoid co-administration with streptomycin.
Non-depolarizing muscle relaxants (e.g., atracurium, pancuronium, tubocurarine, gallamine triethiodide): may increase risk of neuromuscular blockade with large doses. Use with close monitoring.

SPECTRUM

Gram-negatives

Detailed Spectrum of Activity

RESISTANCE

Enterococci synergy with ampicillin if MIC <1000 mcg/mL.

PHARMACOLOGY

Pharmacology

COMMENTS

Parenteral aminoglycoside with the most ototoxicity potential. Use is generally limited to treatment of multiple-drug resistant tuberculosis (MDRTB), but high rates of streptomycin resistance has been described in high-incidence countries. Also used for unusual infections: plague, tularemia and brucellosis. May be synergistic with ampicillin in cases of gentamicin resistant enterococcusendocarditis.

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