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Tobramycin (systemic): Drug information

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

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Nephrotoxicity:

Tobramycin can result in acute kidney injury, including acute renal failure. Risk factors that may contribute to nephrotoxicity include tobramycin accumulation (increasing serum trough levels), high peak concentrations (>12 mcg/mL), total cumulative dose, advanced age, volume depletion, and concurrent or sequential use of other nephrotoxic drugs. Avoid concurrent or sequential use of other potentially nephrotoxic drugs. Monitor serum tobramycin levels and renal function in all patients during drug treatment. Reduce the dose or discontinue tobramycin if renal impairment occurs.

Ototoxicity:

Tobramycin can cause irreversible auditory and vestibular toxicity that may continue to develop after the drug has been discontinued. Risk factors include high serum concentrations, prolonged therapy, renal impairment, concurrent and sequential use of other nephrotoxic or ototoxic drugs (eg, aminoglycosides), and extremes of age. Avoid concurrent or sequential use with other potentially ototoxic drugs. Monitor for signs and symptoms of auditory and vestibular toxicity. Reduce the dose or discontinue tobramycin if renal impairment occurs. Discontinue tobramycin if ototoxicity occurs.

Neuromuscular blockade:

Aminoglycosides have been associated with neuromuscular blockade. During therapy with tobramycin, monitor for adverse reactions associated with neuromuscular blockade, particularly in high-risk patients, such as patients with underlying neuromuscular disorders (including myasthenia gravis) or in patients concomitantly receiving neuromuscular-blocking agents.

Embryo-fetal toxicity:

Tobramycin and other aminoglycosides can cause fetal harm when administered to a pregnant woman. If tobramycin is used during pregnancy or if the patient becomes pregnant while taking tobramycin, apprise the patient of the potential hazard to the fetus.

Brand Names: Canada
  • JAMP-Tobramycin [DSC]
Pharmacologic Category
  • Antibiotic, Aminoglycoside
Dosing: Adult

Note: 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 Vd (eg, critically ill). For obese patients (ie, TBW >1.25 × IBW), use adjusted body weight ([0.4 × (TBW-IBW)] + IBW) for initial weight-based dosing and for estimating kidney function with Cockcroft-Gault (CrCL) (Ref). Therapeutic drug monitoring: Monitoring of serum concentrations is recommended to ensure efficacy and avoid toxicity, particularly in critically ill patients with serious infection or in disease states known to significantly alter aminoglycoside pharmacokinetics (eg, cystic fibrosis, burns, major surgery). Timing and frequency of concentration monitoring is individualized based on dosing and monitoring strategy (Ref).

Usual dosage range:

Gram negative infections:

Conventional/traditional dosing: IV, IM: 3 to 5 mg/kg/day in divided doses every 8 hours (Ref). Some experts favor an initial loading dose of 2.5 to 3 mg/kg (Ref). Target peak concentration depends on indication and site of infection; in general, adjust dose to achieve peak of 4 to 6 mg/L for urinary tract infections and 7 to 10 mg/L for serious infections (including life-threatening infections). Target trough concentrations should be <2 mg/L; ideal target <1 mg/L (Ref).

High-dose extended-interval dosing (once-daily dosing): IV: 5 to 7 mg/kg once daily; use with caution in patients with CrCl <40 mL/minute (Ref). Adjust tobramycin dose and interval to achieve an extrapolated peak concentration of ~15 to 20 mg/L and trough concentration ≤1 mg/L; ideal target <0.5 mg/L (Ref). Note: Published nomograms for dosage adjustment may not apply to patients with altered pharmacokinetics (eg, patients with ascites, burns covering >20% total BSA, end-stage renal disease requiring dialysis, pregnancy) (Ref).

Indication-specific dosing:

Bloodstream infection

Bloodstream infection: Adjunctive empiric therapy for patients with concern for resistant gram-negative bacteria (eg, immunosuppression, prevalent local resistance, recent antibiotic exposure): IV: 5 to 7 mg/kg once daily in combination with a second gram-negative active agent; once culture and susceptibility results are available, can generally discontinue and use a single agent with documented activity. Tobramycin should not be used as monotherapy (Ref).

Cerebrospinal fluid shunt infection

Cerebrospinal fluid shunt infection (adjunct to systemic therapy): Note: Reserve for infections due to multidrug-resistant organisms, infections refractory to appropriate parenteral therapy, or when infected shunts cannot be removed (Ref).

Intraventricular (use a preservative-free preparation): 5 to 20 mg/day; some experts recommend adjusting dosage and administration interval based on cerebrospinal fluid (CSF) tobramycin concentrations (goal: 10 to 20 times minimum inhibitory concentration of causative organism), ventricle size, and daily output from ventricular drain (Ref). When intraventricular tobramycin is administered via a ventricular drain, clamp drain for 15 to 60 minutes after administration (allows solution to equilibrate in CSF). Duration is individualized according to clinical and microbiological response (Ref).

Cystic fibrosis, acute pulmonary exacerbation

Cystic fibrosis, acute pulmonary exacerbation: For empiric or targeted therapy of P. aeruginosa or other gram-negative bacilli:

IV: 10 mg/kg once daily as part of an appropriate combination regimen (Ref). Duration is usually 10 to 14 days depending on clinical response (Ref).

Meningitis, bacterial

Meningitis, bacterial: P. aeruginosa: IV: 5 mg/kg/day in divided doses every 8 hours as part of an appropriate combination regimen (Ref).

Peritonitis, treatment

Peritonitis, treatment (peritoneal dialysis patients) (off-label use): As a component of empiric therapy or for pathogen-directed therapy.

Note: Intraperitoneal administration is preferred to IV administration. Once culture results are available, switch to another active antibiotic class, if possible, to decrease the risk of toxicity; otherwise, duration of therapy is ≥3 weeks for patients with adequate clinical response (Ref). Consider a 25% dose increase in patients with significant residual renal function (urine output >100 mL/day) (Ref).

Intermittent (strongly preferred): Intraperitoneal: 0.6 mg/kg added to one exchange of dialysis solution once daily (allow to dwell ≥6 hours) (Ref).

Continuous (with every exchange): Intraperitoneal: Loading dose: 3 mg/kg with first exchange of dialysate; maintenance dose: 0.3 mg/kg with each subsequent exchange of dialysate (Ref).

Plague, treatment

Plague (Yersinia pestis), treatment (alternative agent) (off-label use):

Note: Consult public health officials for event-specific recommendations.

IV, IM: 5 to 7 mg/kg once daily for 7 to 14 days and for at least a few days after clinical resolution (Ref).

Pneumonia, hospital-acquired or ventilator-associated

Pneumonia, hospital-acquired or ventilator-associated (alternative agent):

Note: Some experts reserve for patients with risk for multidrug-resistant pathogens (Ref).

IV: 5 to 7 mg/kg once daily in combination with a second gram-negative agent; once culture and susceptibility results are available, can generally discontinue tobramycin and use a single agent with documented activity (Ref). Note: Avoid use of tobramycin monotherapy (Ref).

Sepsis or septic shock, adjunctive empiric gram-negative coverage

Sepsis or septic shock, adjunctive empiric gram-negative coverage (eg, in the setting of intra-abdominal infection, pneumonia, gram-negative bacteremia, or severe burn): Note: Some experts reserve for patients with immunocompromising conditions or risk for resistant gram-negative pathogens, in particular P. aeruginosa (Ref).

IV: 5 to 7 mg/kg once daily in combination with a second gram-negative agent (Ref); once culture and susceptibility tests are available, can generally discontinue and use a single agent with documented activity. Tobramycin should not be used as monotherapy for severe infections outside of the urinary tract (Ref).

Urinary tract infection, complicated

Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms) (alternative agent): Note: Some experts reserve for use when other long-acting parenteral antimicrobials (eg, ceftriaxone) or fluoroquinolones cannot be used due to allergy, intolerance, unmodifiable drug interactions, or resistance (Ref).

Inpatients: IV, IM: 5 mg/kg once daily. Switch to an appropriate oral regimen once symptoms improve, if culture and susceptibility results allow. Total duration of therapy ranges from 5 to 14 days and depends on clinical response and the antimicrobial chosen to complete the regimen (Ref).

Outpatients: IV, IM: 5 mg/kg once, followed by 5 to 14 days of appropriate oral therapy (Ref). Note: For patients who are systemically ill or at risk for more severe illness, some experts continue daily parenteral therapy pending culture and susceptibility results (Ref).

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

Dosing: Kidney Impairment: Adult

IM, IV:

Conventional dosing:

CrCl >60 mL/minute: Administer every 8 hours.

CrCl 40 to 60 mL/minute: Administer every 12 hours.

CrCl 20 to 39 mL/minute: Administer every 24 hours.

CrCl <20 mL/minute: Loading dose, then monitor levels.

IV:

High-dose extended-interval dosing (Ref): Interval may be extended (eg, every 36 to 48 hours) in patients with renal impairment and/or adjusted based on therapeutic drug monitoring.

CrCl ≥60 mL/minute: Administer every 24 hours.

CrCl 40 to 59 mL/minute: Administer every 36 hours.

CrCl 20 to 39 mL/minute: Administer every 48 hours.

CrCl <20 mL/minute: Monitor serum levels and redose when tobramycin level is <1 mg/L or use conventional dosing.

Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days) (Ref): Dialyzable (25% to 70%; variable; dependent on filter, duration, and type of HD): IV:

Loading dose of 2 to 3 mg/kg, followed by:

Mild UTI: 1 mg/kg/dose every 48 to 72 hours; consider redosing for pre-HD or post-HD serum concentrations <1 mg/L.

Moderate to severe UTI: 1 to 1.5 mg/kg/dose every 48 to 72 hours; consider redosing for pre-HD serum concentrations <1.5 to 2 mg/L or post-HD concentrations <1 mg/L.

Systemic gram-negative infection: 1.5 to 2 mg/kg/dose every 48 to 72 hours; consider redosing for pre-HD serum concentrations <3 to 5 mg/L or post-HD serum concentrations <2 mg/L.

Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions.

CRRT (Ref): 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 target drug concentrations (if appropriate). Note: The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1 to 2 L/hour and minimal residual renal function) and should not supersede clinical judgment; therapeutic drug monitoring is recommended:

CVVH/CVVHD/CVVHDF: IV:

Mild UTI: Loading dose of 2 to 3 mg/kg, followed by 1 mg/kg/dose every 24 to 36 hours (redose when serum concentration <1 mg/L (Ref)).

Moderate-severe UTI: Loading dose of 2 to 3 mg/kg, followed by 1 to 1.5 mg/kg/dose every 24 to 36 hours (redose when serum concentration <1.5 to 2 mg/L (Ref)).

Systemic gram-negative infection: Loading dose of 2 to 3 mg/kg, followed by 1.5 to 2.5 mg/kg/dose every 24 to 48 hours (generally accepted to redose when serum concentration <2 mg/L; one reference suggests redosing when <3 mg/L (Ref)).

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary; does not undergo hepatic metabolism.

Dosing: Obesity: Adult

The recommendations for dosing in patients with obesity are based upon the best available evidence and clinical expertise. Senior Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.

Class 1, 2, or 3 obesity (BMI ≥30 kg/m2):

IV: Use adjusted body weight for initial weight-based dosing when targeting Cmax/minimum inhibitory concentration (MIC) goals with either loading dose equation (based on target aminoglycoside concentration and estimated Vd) or mg/kg approach and when estimating kidney function with Cockcroft-Gault (CrCl) (Ref). Alternatively, use adjusted body weight to estimate CrCl and aminoglycoside dosing with the Bayesian approach when targeting AUC/MIC goals (Ref). Note: If aminoglycoside therapy is continued, use Cmax/MIC or AUC/MIC goals to optimize therapy, especially in the critically ill where weight and kidney function may be poor surrogates of Vd and clearance (Ref).

Rationale for recommendations: Aminoglycosides are hydrophilic medications with a low Vd and clearance that is proportional to GFR. Pharmacokinetic studies have observed adjusted body weight, using a correction factor of 0.4, is the most appropriate weight metric to correct Vd in the setting of obesity. However, there is wide variation in the correction factors reported, which could lead to under- or overdosing in clinical practice (Ref). Early use of therapeutic drug monitoring is recommended (Ref).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Tobramycin (systemic): Pediatric drug information")

Note: Initial dosing recommendations presented. Monitoring of serum concentrations is recommended to ensure efficacy and avoid toxicity, particularly in critically ill patients with serious infection or in disease states known to significantly alter aminoglycoside pharmacokinetics (eg, cystic fibrosis, burns, major surgery). Timing and frequency of concentration monitoring is individualized based on dosing and monitoring strategy (Ref). Routes of administration may vary (including IM, IV, intraperitoneal, intrathecal, and intraventricular); use caution. Some dosing is based on gentamicin studies.

Dosing consideration for obesity: In obese pediatric patients, use adjusted body weight (IBW + 0.4 [TBW – IBW]) to calculate initial dosage (Ref). Alternatively, adjusted body weight for obese pediatric patients may be calculated using the equation 0.7 x TBW (Ref), or fat-free mass can be used to calculate the initial dose in pediatric patients ≥2 years regardless of body habitus (Ref). Dosage should then be individualized based upon serum concentration monitoring.

General dosing, susceptible infection: Note: Optimal dose and frequency not established in patients receiving extracorporeal membrane oxygenation (ECMO); patient-specific considerations (eg, reason for ECMO) and variability with ECMO procedure itself make extrapolation of pharmacokinetic data and dosing to all patients receiving ECMO difficult; closely monitor serum concentrations and determine individual dosing needs in these patients.

Conventional dosing: Infants, Children, and Adolescents: IM, IV: 6 to 7.5 mg/kg/day divided every 6 to 8 hours (Ref).

Extended-interval dosing: Limited data available:

Weight-directed: Infants, Children, and Adolescents: IV: 5 to 7.5 mg/kg/dose every 24 hours (Ref).

Age-directed: Based on data from 114 pediatric patients receiving extended-interval dosing of gentamicin, the following has been suggested for tobramycin (Ref):

Infants ≥3 months and Children <2 years: IV: 9.5 mg/kg/dose every 24 hours.

Children 2 to <8 years: IV: 8.5 mg/kg/dose every 24 hours.

Children ≥8 years and Adolescents: IV: 7 mg/kg/dose every 24 hours.

Cystic fibrosis, pulmonary infection

Cystic fibrosis, pulmonary infection: Infants, Children, and Adolescents:

Conventional dosing: IM, IV: 3.3 mg/kg/dose every 8 hours (Ref).

Extended-interval dosing: IV: Initial: 10 to 12 mg/kg/dose every 24 hours (Ref); maximum reported dose from a survey of 28 Cystic Fibrosis (CF) Foundation-accredited centers ranged from 12 to 20 mg/kg/dose (Ref). Note: The CF Foundation recommends extended-interval dosing as preferred over conventional dosing.

Endocarditis, treatment

Endocarditis, treatment: Limited data available:

Synergy dosing (eg, gram-positive bacteria): Children and Adolescents: IV: 3 to 6 mg/kg/day divided every 8 hours; use in combination with other antibiotics dependent upon pathogen and source of infection (ie, valve-type) (Ref).

Treatment dosing (eg, gram-negative bacteria): Children and Adolescents: IV: 7.5 mg/kg/day divided every 8 hours; use in combination with other antibiotics (Ref).

Intra-abdominal infection, complicated

Intra-abdominal infection, complicated: Infants, Children, and Adolescents: IV: 3 to 7.5 mg/kg/day divided every 8 to 24 hours; use in combination with other antibiotics (Ref).

CNS infection

CNS infection:

Meningitis, including health care-associated meningitis: Limited data available: Infants, Children, and Adolescents: IV: Initial: 7.5 mg/kg/day divided every 8 hours in combination with additional antimicrobials; duration should be individualized based on patient characteristics, infecting organism, and response (Ref).

Ventriculitis (including health care-associated ventriculitis and cerebrospinal fluid [CSF] shunt infections): Limited data available: Infants, Children, and Adolescents: Intraventricular, intrathecal: Use a preservative-free preparation: 5 to 20 mg/day (Ref). Due to the smaller CSF volume in infants, some guidelines recommend decreasing the infant dose; dosage and administration interval can also be adjusted based on CSF tobramycin concentrations, ventricle size, and daily output from ventricular drain (Ref). Duration is individualized according to clinical and microbiological response (Ref).

Peritonitis

Peritonitis (peritoneal dialysis) (Ref): Limited data available: Infants, Children, and Adolescents: Intraperitoneal: Continuous: Loading dose: 8 mg per liter of dialysate; maintenance dose: 4 mg per liter.

Urinary tract infection

Urinary tract infection:

Conventional dosing: Infants, Children, and Adolescents: IV: 5 mg/kg/day divided every 8 hours until clinical improvement and able to tolerate oral intake; complete course with oral antibiotics; duration should be individualized based upon age, severity, and degree of urinary tract involvement (eg, patients <24 months or with pyelonephritis: 7 to 14 days; older patients with uncomplicated cystitis: 3 to 7 days) (Ref).

Extended-interval dosing: Limited data available: Based on data from 90 patients (ages: 1 month to 12 years) receiving gentamicin, the following age-directed dosing has been suggested (Ref): Note: Patients were transitioned to oral therapy once afebrile for 24 hours.

Infants and Children <5 years: IV: 7.5 mg/kg/dose every 24 hours.

Children 5 to 10 years: IV: 6 mg/kg/dose every 24 hours.

Children 11 to 12 years: IV: 4.5 mg/kg/dose every 24 hours.

Single-dose regimen: Limited data available. Note: Recommended for treatment of uncomplicated cystitis caused by antimicrobial resistant gram-negative pathogens (Ref):

Infants, Children, and Adolescents: IM: 5 mg/kg as a single dose; dosing based on 2 prospective studies evaluating single-dose IM gentamicin in patients 1 month to 15 years and a systematic review evaluating studies of various single-dose aminoglycosides in pediatric and adult patients (Ref); one study limited doses to 300 mg (Ref). An overall pooled cure rate for single dose IM aminoglycoside for treatment of children and adults with mainly uncomplicated cystitis was reported as 94.5% ± 4.3% (Ref). Note: Guidelines do not address pediatric dosing; recommended aminoglycoside doses in adults include IV single doses (Ref).

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

Dosing: Kidney Impairment: Pediatric

Parenteral: Note: Tobramycin serum concentrations should be monitored in patients with kidney impairment; following the initial dose, subsequent doses may be determined based on therapeutic monitoring.

Infants, Children, and Adolescents: IM, IV:

The following adjustments have been recommended (Ref): Note: Renally adjusted dose recommendations are based on doses of 2.5 mg/kg/dose every 8 hours.

GFR >50 mL/minute/1.73 m2: No adjustment required.

GFR 30 to 50 mL/minute/1.73 m2: Administer every 12 to 18 hours.

GFR 10 to 29 mL/minute/1.73 m2: Administer every 18 to 24 hours.

GFR <10 mL/minute/1.73 m2: Administer every 48 to 72 hours.

Intermittent hemodialysis: Dialyzable (25% to 70%): 2 mg/kg/dose; redose as indicated by serum concentrations.

Peritoneal dialysis (PD): 2 mg/kg/dose; redose as indicated by serum concentrations.

Continuous renal replacement therapy (CRRT): 2 to 2.5 mg/kg/dose every 12 to 24 hours, monitor serum concentrations.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however, dosage adjustment not likely to be necessary (does not undergo hepatic metabolism).

Adverse Reactions

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

Frequency not defined:

Central nervous system: Confusion, disorientation, dizziness, headache, lethargy, vertigo

Dermatologic: Exfoliative dermatitis, pruritus, skin rash, urticaria

Endocrine & metabolic: Decreased serum calcium, decreased serum magnesium, decreased serum potassium, decreased serum sodium, increased lactate dehydrogenase, increased nonprotein nitrogen

Gastrointestinal: Diarrhea, nausea, vomiting

Genitourinary: Casts in urine, oliguria, proteinuria

Hematologic & oncologic: Anemia, eosinophilia, granulocytopenia, leukocytosis, leukopenia, thrombocytopenia

Hepatic: Increased serum ALT, increased serum AST, increased serum bilirubin

Local: Pain at injection site

Otic: Auditory ototoxicity, hearing loss, tinnitus, vestibular ototoxicity

Renal: Increased blood urea nitrogen, increased serum creatinine

Miscellaneous: Fever

<1%, postmarketing, and/or case reports: Anaphylaxis, Clostridioides difficile-associated diarrhea, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis

Contraindications

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

Warnings/Precautions

Concerns related to adverse effects:

• Hypersensitivity: Severe allergic reactions (some fatal), including anaphylaxis, and dermatologic reactions (eg, exfoliative dermatitis, toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome) have been reported; discontinue therapy and initiate appropriate treatment if allergic reaction occurs.

• Nephrotoxicity: [US Boxed Warning]: May cause acute kidney injury, including acute renal failure. Risk factors include tobramycin accumulation (increasing serum trough levels), high peak concentrations (>12 mcg/mL), total cumulative dose, advanced age, volume depletion, and concurrent or sequential use of other nephrotoxic drugs. Avoid concurrent or sequential use of other potentially nephrotoxic drugs. Monitor serum tobramycin levels and renal function in all patients during drug treatment. Reduce the dose or discontinue the drug if renal impairment occurs. Kidney injury is usually reversible.

• Neuromuscular blockade: [US Boxed Warning]: Aminoglycosides have been associated with neuromuscular blockade. Monitor for adverse reactions associated with neuromuscular blockade during therapy, particularly in high-risk patients, such as patients with underlying neuromuscular disorders (including myasthenia gravis) or in patients concomitantly receiving neuromuscular-blocking agents. Neuromuscular blockade may lead to respiratory failure and prolonged respiratory paralysis; additional signs of neurotoxicity may include numbness, skin tingling, muscle twitching, and convulsions. Neuromuscular blockade is reversible but may require treatment (eg, administration of calcium salts).

• Ototoxicity: [US Boxed Warning]: May cause irreversible auditory and vestibular toxicity that may continue to develop after discontinuation. Risk factors include high serum concentrations, prolonged therapy, renal impairment, concurrent and sequential use of other nephrotoxic or ototoxic drugs (eg, aminoglycosides), and extremes of age. Avoid concurrent or sequential use with other potentially ototoxic drugs. Monitor for signs and symptoms of auditory and vestibular toxicity. Reduce the dose or discontinue therapy if renal impairment occurs. Discontinue use if ototoxicity occurs. Auditory changes are usually bilateral and may be partial or total. Ototoxicity symptoms may include dizziness, vertigo, tinnitus, roaring in the ears and hearing loss; consider serial audiograms in high-risk patients.

• 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.

• Hypocalcemia: Use with caution in patients with hypocalcemia.

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

• Renal impairment: Use with caution in patients with preexisting renal insufficiency; dosage modification required during systemic therapy.

Special populations:

• Patients with genomic variants in MT-RNR1: Carriers of certain variants in the MT-RNR1 gene (eg, m.1555A>G) may be at increased risk for aminoglycoside-induced ototoxicity, including potentially significant hearing loss that may be irreversible, even when serum levels are within the normal range.

Dosage form specific issues:

• Sulfite: Solution for injection may contain sodium metabisulfate; use caution in patients with sulfite allergy.

Other warnings/precautions:

• Appropriate use: Not for intraocular and/or subconjunctival administration; macular necrosis has been reported following administration of aminoglycosides by these routes.

• Long-term use: Systemic therapy is not intended for long-term therapy due to toxic hazards associated with extended administration.

Warnings: Additional Pediatric Considerations

Use with caution in premature infants and neonates; immature renal function may increase risk of accumulation and related toxicity. Use with caution in pediatric patients on extracorporeal membrane oxygenation (ECMO); pharmacokinetics of aminoglycosides may be altered; dosage adjustment and close monitoring necessary.

Dosage Forms: US

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

Solution, Injection:

Generic: 10 mg/mL (2 mL); 80 mg/2 mL (2 mL); 1.2 g/30 mL (30 mL)

Solution, Injection [preservative free]:

Generic: 80 mg/2 mL (2 mL); 2 g/50 mL (50 mL)

Solution Reconstituted, Injection:

Generic: 1.2 g (1 ea)

Solution Reconstituted, Injection [preservative free]:

Generic: 1.2 g (1 ea)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Tobramycin Sulfate Injection)

1.2 g/30 mL (per mL): $0.86 - $0.88

2 gm/50 mL (per mL): $1.26

10 mg/mL (per mL): $3.68

80 mg/2 mL (per mL): $0.93 - $2.03

Solution (reconstituted) (Tobramycin Sulfate Injection)

1.2 g (per each): $86.40 - $218.75

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.

Dosage Forms: Canada

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

Solution, Injection:

Generic: 10 mg/mL (2 mL)

Solution, Injection, as sulfate:

Generic: 40 mg/mL (2 mL, 30 mL)

Solution Reconstituted, Injection:

Generic: 1.2 g (1 ea)

Administration: Adult

IM: May be administered IM by withdrawing the appropriate dose directly from a vial or by using a prefilled syringe. The pharmacy bulk package and tobramycin in sodium chloride 0.9% is not intended for IM administration.

IV: Administer by intermittent infusion over 20 to 60 minutes; higher doses are generally administered over 60 minutes (Ref). Flush line with saline before and after administration.

Intraventricular (off-label route): Use preservative-free preparations only. When administered through a ventricular drain, clamp drain for 15 to 60 minutes before opening the drain to allow tobramycin solution to equilibrate in the CSF (Ref).

Administration: Pediatric

Parenteral:

IM: May be administered undiluted.

IV: Administer by intermittent infusion over 20 to 60 minutes; shorter infusion times (≤5 minutes) have been reported in pediatric patients, including preterm and term neonates, receiving ≤4 mg/kg/dose (Ref). Avoid infusing concomitantly with penicillins or cephalosporins if feasible; consult drug interactions database for more information.

Intrathecal/Intraventricular: Use preservative-free preparations only; must be diluted prior to administration. No specific administration information available; it has been suggested that instillation of small volumes (<3 mL) over 1 to 2 minutes is safe (Ref). When administered through a ventricular drain, clamp drain for 15 to 60 minutes to allow tobramycin solution to equilibrate in the cerebrospinal fluid (CSF) (Ref).

Use: Labeled Indications

Bloodstream infection: Treatment of bloodstream infection caused by Pseudomonas aeruginosa, Escherichia coli, and Klebsiella spp., in adult and pediatric patients.

Bone infections: Treatment of bone infections caused by P. aeruginosa, Proteus spp., E. coli, Klebsiella spp., Enterobacter spp., and Staphylococcus aureus in adult and pediatric patients.

Intra-abdominal infections: Treatment of intra-abdominal infections, including peritonitis, caused by E. coli, Klebsiella spp., and Enterobacter spp. in adult and pediatric patients.

Meningitis, bacterial: Treatment of bacterial meningitis caused by susceptible bacteria in adult and pediatric patients.

Pneumonia: Treatment of pneumonia caused by P. aeruginosa, Klebsiella spp., Enterobacter spp., Serratia spp., E. coli, and Staphylococcus aureus in adult and pediatric patients.

Skin and skin structure infections: Treatment of skin and skin structure infections caused by P. aeruginosa, Proteus spp., E. coli, Klebsiella spp., Enterobacter spp., and S. aureus in adult and pediatric patients.

Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms): Treatment of complicated urinary tract infections caused by P. aeruginosa, Proteus spp., (indole-positive and indole-negative), E. coli, Klebsiella spp., Enterobacter spp., Serratia spp., S. aureus, Providencia spp., and Citrobacter spp. in adult and pediatric patients.

Use: Off-Label: Adult

Peritonitis, treatment (peritoneal dialysis patients); Plague (Yersinia pestis), treatment

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

Tobramycin may be confused with Trobicin, vancomycin

International issues:

Nebcin [Multiple international markets] may be confused with Naprosyn brand name for naproxen [US, Canada, and multiple international markets]; Nubain brand name for nalbuphine [Multiple international markets]

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication (intrathecal administration) among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Aminoglycosides: May enhance the nephrotoxic effect of other Aminoglycosides. Aminoglycosides may enhance the neurotoxic effect of other Aminoglycosides. Risk X: Avoid combination

Amphotericin B: May enhance the nephrotoxic effect of Aminoglycosides. Amphotericin B may enhance the neurotoxic 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

Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification

Bacitracin (Systemic): May enhance the nephrotoxic effect of Aminoglycosides. Bacitracin (Systemic) may enhance the neurotoxic effect of Aminoglycosides. 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: May enhance the nephrotoxic effect of Aminoglycosides. 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. CISplatin may enhance the neurotoxic effect of Aminoglycosides. Risk X: Avoid combination

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

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

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

Fecal Microbiota (Live) (Oral): May diminish the therapeutic effect of Antibiotics. Risk X: Avoid combination

Fecal Microbiota (Live) (Rectal): Antibiotics may diminish the therapeutic effect of Fecal Microbiota (Live) (Rectal). Risk X: Avoid combination

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

Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Risk C: Monitor therapy

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

Netilmicin (Ophthalmic): Aminoglycosides may enhance the nephrotoxic effect of Netilmicin (Ophthalmic). 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

Polymyxin B: May enhance the nephrotoxic effect of Aminoglycosides. Polymyxin B may enhance the neurotoxic effect of Aminoglycosides. Risk X: Avoid combination

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. Vancomycin may enhance the neurotoxic effect of Aminoglycosides. Management: Consider avoiding coadministration of aminoglycosides and vancomycin unless clinically indicated. If coadministered, monitor closely for signs of nephrotoxicity and neurotoxicity. Risk D: Consider therapy modification

Pregnancy Considerations

Tobramycin crosses the placenta.

Tobramycin and other aminoglycosides can cause fetal harm when administered to a pregnant patient. If tobramycin is used during pregnancy or if the patient becomes pregnant while taking tobramycin, apprise the patient of the potential hazard to the fetus.

There are several reports of total irreversible bilateral congenital deafness in children whose mothers received another aminoglycoside (streptomycin) during pregnancy. Although serious side effects to the fetus/infant have not been reported following maternal use of all aminoglycosides, a potential for harm exists.

Due to pregnancy-induced physiologic changes, some pharmacokinetic parameters of tobramycin may be altered (Bourget 1991).

Tobramycin injection may be used for the management of cystic fibrosis in pregnant patients with P. aeruginosa (inhalation is preferred unless risk of infection is great) (Edenborough 2008) and as an alternative antibiotic for prophylactic use prior to cesarean delivery (Bratzler 2013).

Tobramycin is used in the management of plague (Yersinia pestis). Untreated infections in pregnant patients may result in hemorrhage (including postpartum hemorrhage), maternal and fetal death, preterm birth, and stillbirth. Limited data suggest maternal-fetal transmission of Y. pestis can occur if not treated. Pregnant patients should be treated for Y. pestis; parenteral antibiotics are preferred for initial treatment when otherwise appropriate. Tobramycin is an alternative aminoglycoside recommended for use (in combination with a fluroquinolone) for treating pregnant patients with bubonic, pharyngeal, pneumonic, or septicemic plague (CDC [Nelson 2021]).

Breastfeeding Considerations

Tobramycin is present in breast milk following injection (Festini 2006; Uwaydah 1975).

In general, modification of bowel flora may occur with any antibiotic exposure (Chung 2002). Breastfed infants should be monitored for loose or bloody stools, thrush, and diaper rash.

According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. Aminoglycosides have poor oral bioavailability and therefore use may be considered in patients who are breastfeeding (Panchaud 2016).

Dietary Considerations

May require supplementation of calcium, magnesium, potassium.

Monitoring Parameters

Urinalysis, urine output, BUN, serum creatinine, peak and trough plasma tobramycin levels. Levels are typically obtained after the third dose in conventional dosing. Be alert to ototoxicity; hearing should be tested before and during treatment

Some penicillin derivatives may accelerate the degradation of aminoglycosides in vitro. This may be clinically-significant for certain penicillin (ticarcillin, piperacillin, carbenicillin) and aminoglycoside (gentamicin, tobramycin) combination therapy in patients with significant renal impairment. Close monitoring of aminoglycoside levels is warranted.

Reference Range

Conventional/traditional dosing:

Timing of serum samples: Draw peak 30 minutes after 30-minute infusion has been completed or 1 hour following IM injection or beginning of infusion; draw trough immediately before next dose is due. Obtain drug levels after the third dose unless renal dysfunction/toxicity expected.

Therapeutic levels:

Peak:

Sepsis, pneumonia, and other serious infections: 7 to 10 mg/L (Drew 2020; Matzke 1983).

Urinary tract infections, including pyelonephritis: 4 to 6 mg/L.

Cystic fibrosis (P. aeruginosa): 20 to 30 mg/L (Simon 2021).

Trough:

Gram negative infections: <2 mg/L; ideal target <1 mg/L (Bertino 1994; Drew 2020; Matzke 1983).

High-dose extended-interval dosing (once-daily dosing): Obtain a random tobramycin level between 6 and 14 hours after the start of the tobramycin infusion. Refer to institution-specific nomogram/policies to determine appropriate dosing interval. Alternatively, obtain 2 random tobramycin levels and adjust dose and interval to achieve an extrapolated peak concentration of ~15 to 20 mcg/mL and trough concentration ≤1 mcg/mL; ideal target <0.5 mcg/mL (Buijk 2002; Drew 2020; Leggett 2014; Nicolau 1995; Pagkalis 2011). When therapy is continued for 5 days or more, monitor the tobramycin levels once or twice weekly (Bailey 1997; Nicolau 1995).

Intraventricular therapeutic drug monitoring: Limited data available (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]): Prior to administration of the next intraventricular dose, withdraw a sample of cerebrospinal fluid (CSF). This trough cerebrospinal fluid concentration divided by the tobramycin minimum inhibitory concentration of the isolated bacterial pathogen (inhibitory quotient) should exceed 10 to 20.

Mechanism of Action

Interferes with bacterial protein synthesis by binding to 30S ribosomal subunit, resulting in a defective bacterial cell membrane

Pharmacokinetics (Adult Data Unless Noted)

Absorption:

Oral: Poorly absorbed.

IM: Rapid and complete.

Distribution: Distributes to extracellular fluid, including serum, abscesses, ascitic, pericardial, pleural, synovial, lymphatic, and peritoneal fluids; poor penetration into CSF, eye, bone, prostate.

Vd: Varies with age; increased in patients with edema, ascites, fluid overload; decreased in patients with dehydration:

Neonates: 0.45 ± 0.1 L/kg.

Infants: 0.4 ± 0.1 L/kg.

Children: 0.35 ± 0.15 L/kg.

Adolescents: 0.3 ± 0.1 L/kg.

Adults: 0.2 to 0.3 L/kg.

CSF:blood level ratio: Normal meninges: <10%; Inflamed meninges: ≤25% (MacDougall 2011).

Lung: Epithelial lining fluid Cmax (peak):serum Cmax (peak) ratio: ~12% to 30%, varies with time (Boselli 2007; Carcas 1999; Heffernan 2019; Rodvold 2011).

Protein binding: <30%.

Half-life elimination:

Neonates: ≤1,200 g: 11 hours; >1,200 g: 2 to 9 hours.

Infants: 4 ± 1 hour.

Children: 2 ± 1 hour.

Adolescents: 1.5 ± 1 hour.

Adults: IV: 2 to 3 hours; directly dependent upon glomerular filtration rate.

Adults with impaired renal function: 5 to 70 hours.

Time to peak, serum: IM: 30 to 60 minutes; IV: ~30 minutes.

Note: Distribution is prolonged after larger doses (≥60 minutes after 60-minute infusion of 10 mg/kg [Aminimanizani 2002]; ≥90 minutes after 60-minute infusion of a high-dose aminoglycoside [gentamicin 7 mg/kg] [Demczar 1997]).

Excretion: Normal renal function: Urine (~90% to 95%) within 24 hours.

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Clearance is decreased in renal impairment.

Anti-infective considerations:

Parameters associated with efficacy:

Gram-negative bacilli: Concentration-dependent, associated with Cmax (peak)/minimum inhibitory concentration (MIC), goal: ≥8 to 10 (Craig 2011; Kashuba 1999; Moore 1987; Zelenitsky 2003) or AUC24/MIC, goal: 30 to 50 (mild/moderate infection) or 80 to 100 (severe infection) (Bland 2018; Craig 2011; Drusano 2007; Smith 2001).

P. aeruginosa in patients with cystic fibrosis: Cmax (peak)/MIC ≥10, AUC/MIC ≥50 (Burkhardt 2006).

Expected drug exposure in adults with normal renal function:

Cmax (peak), postdistributional: 7 mg/kg: ~20 to 22 mg/mL (Craig 2011; Finnell 1998).

AUC24:

Cystic fibrosis:

10 mg/kg: ~108 mg•hour/L (Aminimanizani 2002).

7 mg/kg: 70 to 110 mg•hour/L (Barclay 1995; Craig 2011; Finnell 1998).

Critically ill: 5 mg/kg: ~86 mg•hour/L (Conil 2011).

Parameters associated with toxicity: Nephrotoxicity is associated with more frequent administration and elevated Cmin (trough) concentrations leading to renal accumulation (Bertino 1993; Rybak 1999).

Postantibiotic effect: Bacterial killing continues after tobramycin concentration drops below the MIC of targeted pathogen; generally 0.5 to 7.5 hours, though the actual time of postantibiotic effect varies based on multiple factors including organism, tobramycin Cmax (peak), and concomitant antimicrobial therapy (Craig 2011; Gudmundsson 1993; Lacy 1998).

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Nebcin;
  • (AR) Argentina: Tobral | Tobramicina gen med;
  • (AT) Austria: Tobramycin b.braun | Tobrasix;
  • (AU) Australia: Nebcin | Tobra-Day | Tobramycin | Tobramycin mylan | Tobramycin wockhardt;
  • (BD) Bangladesh: Brulamycin;
  • (BE) Belgium: Obracin | Tobramycine B. Braun | Tobramycine mayne pharma (ben);
  • (BG) Bulgaria: Tobramycin;
  • (BR) Brazil: Tobramina;
  • (CH) Switzerland: Obracin;
  • (CN) China: Nuo neng | Tai xing | Tobramycin | Tuo xin | Yu er ning;
  • (CO) Colombia: Tobra;
  • (CZ) Czech Republic: Brulamycin | Nebcin;
  • (DE) Germany: Gernebcin | Tobra | Tobra cell | Tobramycin b.braun | Tobramycin MP | Tobrazid;
  • (DO) Dominican Republic: Nebcina | Tobra gobens;
  • (EE) Estonia: Brulamycin | Gernebcin | Nebcin | Obracin | Tobramicin | Tobramycin MP | Tobrazid | Tocin;
  • (EG) Egypt: Nebcin | Tobra alex;
  • (ES) Spain: Tobra gobens | Tobramicina normon;
  • (FI) Finland: Nebcina | Tobramycin B Braun | Tomycin;
  • (FR) France: Nebcine | Tobramycine b braun | Tobramycine merck;
  • (GB) United Kingdom: Nebcin | Tobramycin | Tobramycin cox;
  • (GR) Greece: Medphatobra | Nebcin | Tobramycin | Tobramycin Actavis | Tobramycin-mp;
  • (HK) Hong Kong: Nebcin;
  • (HU) Hungary: Brulamycin | Nebcin | Tobramycine cf;
  • (ID) Indonesia: Dartobcin | Tobramycin | Tobryne;
  • (IE) Ireland: Nebcin | Tobramycin;
  • (IL) Israel: Nebcin;
  • (IN) India: Nebracin | Tobacin | Tobex | Tobraneg | Tocin | Toracin;
  • (IT) Italy: Bramicil | Nebicina | Tobramicina | Tobramicina B. Braun;
  • (JO) Jordan: Nebcin;
  • (JP) Japan: Tobracin eli lilly | Tobracin jdolph;
  • (KR) Korea, Republic of: Binex tobramycin | Korus tobramycin | Mytob | Nebcin | Pharmedix tobramycin | Samjin tobramycin | Tenebra | Toberan | Tobicyran | Tobra | Tobramycin | Tobramycin huons | Tobramycin pre-mix | Tobramycin sulfate huons | Tobroxine | Tobucin | Tronamycin;
  • (LB) Lebanon: Nebcin;
  • (LT) Lithuania: Brulamycin | Nebcin;
  • (LU) Luxembourg: Obracin | Tobramycin;
  • (LV) Latvia: Brulamycin | Nebcin;
  • (MA) Morocco: Nebcine;
  • (MX) Mexico: Tobra;
  • (NL) Netherlands: Obracin | Tobramycine;
  • (NO) Norway: Nebcin | Nebcina | Tobramycin B. Braun | Tobramycin x gen;
  • (NZ) New Zealand: Nebcin | Tobra Day | Tobramycin | Tobramycin mylan;
  • (PH) Philippines: Nebcin;
  • (PK) Pakistan: Abbocin | Brulamycin | Magracin | Nebcin | Obramycin | Tobcin | Tobracil | Tobracin | Tobramed | Tobrin | Tocin;
  • (PL) Poland: Brulamycin | Nebcine | Obracin | Tobramycin MP;
  • (PR) Puerto Rico: Nebcin | Tobramycin;
  • (PT) Portugal: Distobram | Tobra gobens | Tobramicina B. Braun | Tobramicina labesfal;
  • (PY) Paraguay: Tobramicina quimfa;
  • (RO) Romania: Tobramicina sun;
  • (RU) Russian Federation: Brulamycin | Nebcin;
  • (SA) Saudi Arabia: Nebcin;
  • (SE) Sweden: Nebcina;
  • (SG) Singapore: Tobramycin;
  • (SI) Slovenia: Bramitob | Gernebicin | Nebcin | Tobramicina normon;
  • (SK) Slovakia: Brulamycin | Tobramycin b.braun;
  • (TH) Thailand: Nebcin;
  • (TN) Tunisia: Nebcine;
  • (TR) Turkey: Nebcin | Tobel;
  • (TW) Taiwan: Biomicin | Nebcin | Tobcin | Tobra | Tobucin | Topramycin | Topsin | Zerodiar;
  • (UA) Ukraine: Braxon | Brulamycin | Tobramycin;
  • (VE) Venezuela, Bolivarian Republic of: Tobra | Tobramicina;
  • (VN) Viet Nam: Intolacin | Union tobracin;
  • (ZA) South Africa: Micro tobramycin | Nebcin | Q-med tobramycin | Tobramycin-fresenius
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