I have to give streptomycin 1gm IM injection to a briucellosis patient

I have to give streptomycin 1gm IM injection to a briucellosis patient. What are the precautions I have to take. What are the side effects I have to monitor for and how to manage them. I have to give it for 21 days 1 gm intramuscular

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brucellosis AND streptomycin

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streptomycin injection prescribing information ototoxicity renal monitoring intramuscular

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https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?set…

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PMID: 39152180

Streptomycin 1 g IM daily for 21 days is a commonly used component of combination treatment for brucellosis, usually with doxycycline. Do not give it as unmonitored monotherapy. Confirm the full prescribed regimen, renal-dose plan, and whether the patient has focal disease such as spondylitis, neurobrucellosis, or endocarditis, which may need specialist-directed treatment.

Before the first dose

Check and document:

Correct patient, drug, vial strength, dose, route, date, and prescribed duration.
History of allergy to streptomycin or another aminoglycoside.
Baseline serum creatinine/eGFR, urea, electrolytes, urine output, and ideally urinalysis.
Baseline hearing and balance symptoms: tinnitus, hearing difficulty, vertigo, unsteady walking. Arrange baseline audiometry if available, especially for a 21-day course.
Pregnancy status in anyone who could be pregnant. Streptomycin can cause fetal ototoxicity and congenital deafness, so the prescriber/obstetric team must urgently review an exposed or pregnant patient.
History of renal disease, older age, pre-existing hearing loss, vestibular disease, dehydration, or myasthenia gravis. These raise toxicity risk.

Review concurrent drugs. Avoid or seek prescriber/pharmacist approval for:

Other aminoglycosides.
Other nephrotoxic drugs, for example vancomycin, amphotericin B, colistin/polymyxins, cisplatin, tacrolimus/cyclosporine, and frequent/high-dose NSAIDs.
Ototoxic drugs, including loop diuretics such as furosemide or ethacrynic acid.
Neuromuscular blockers, magnesium-containing therapy, or drugs likely to depress respiration.

The risk of auditory and vestibular injury rises with cumulative dose, prolonged therapy, renal impairment, age, and pre-existing auditory dysfunction. The DailyMed prescribing information advises baseline and periodic audiometric/vestibular assessment during extended courses.

Safe IM administration

Use the exact product-specific reconstitution instructions. Check clarity, expiry, and final concentration. Do not mix streptomycin with another medication in the same syringe unless the product information specifically permits it.
Give IM only if that is what is prescribed. Do not administer IV.
Use a deep IM injection into a large muscle. Preferred sites include the ventrogluteal site or vastus lateralis/mid-lateral thigh. Avoid injecting close to the sciatic nerve or into inflamed, scarred, indurated, infected, or poorly perfused tissue.
Rotate injection sites daily and document site, side, time, dose, batch/lot if required, and immediate tolerance.
Use aseptic technique. Observe for pain, bleeding, hematoma, swelling, redness, induration, or a sterile abscess.
Encourage adequate oral fluids unless fluid restriction is medically indicated. Dehydration increases renal risk.

What to monitor each day

Ask before each dose:

Hearing/ear symptoms
- Ringing or buzzing in ears
- Ear fullness or roaring noises
- Reduced hearing, especially high-pitched sounds
Vestibular symptoms
- New dizziness, vertigo, nausea/vomiting
- Unsteady gait, difficulty walking in the dark
- New oscillopsia, meaning objects appear to bounce with head movement
Kidney toxicity
- Reduced urine output
- New edema, thirst/dehydration, weakness
- Rising creatinine or urea if results are available
- Proteinuria or casts if urinalysis is being monitored
Neurologic or respiratory effects
- New numbness, tingling, muscle weakness
- Difficulty breathing or swallowing, especially if myasthenia gravis or concurrent anesthetic/neuromuscular-blocking drugs
Allergy and injection-site reaction
- Rash, itching, fever
- Facial/lip/tongue swelling, wheeze, hypotension
- Severe or increasing local pain, redness, warmth, pus, or fluctuance

Suggested monitoring plan for a 21-day course

Time	Monitoring
Before dose 1	Creatinine/eGFR, medication review, pregnancy status, hearing/balance history, baseline audiometry if available
Daily	Symptoms of hearing loss, tinnitus, vertigo, gait instability, nausea/vomiting, urine output, hydration, injection site, allergy
At least weekly, and more often if high risk	Creatinine/eGFR, urea, electrolytes, urine assessment; review cumulative dose and interacting medicines
During or after course if symptoms develop	Audiometry and vestibular assessment urgently
If renal impairment, older age, toxicity concern, or prolonged use	Prescriber/pharmacist should consider therapeutic drug-level monitoring and adjust/hold treatment

Side effects and what to do

Problem	Warning signs	What to do
Vestibulotoxicity	Vertigo, imbalance, nausea/vomiting, unsteady walking	Hold the next dose and contact the prescriber urgently. Prompt cessation can limit injury, but some deficits may persist. Fall precautions and hydration/antiemetic support may be needed.
Cochlear ototoxicity	Tinnitus, ear fullness, new hearing loss	Do not give another dose until prescriber review. Arrange urgent audiometry. Hearing loss can be permanent.
Nephrotoxicity	Oliguria, rising creatinine/eGFR decline, proteinuria	Hold and contact the prescriber. Assess dehydration, stop or replace other nephrotoxic medicines where directed, repeat renal tests, and adjust regimen.
Allergic reaction	Rash, urticaria, fever	Stop administration and inform prescriber. Treat according to local allergy protocol.
Anaphylaxis	Airway swelling, wheeze, hypotension, collapse	Stop drug, call emergency response, manage immediately under local anaphylaxis protocol, including IM adrenaline/epinephrine where indicated. Do not rechallenge unless a specialist directs it.
Neuromuscular blockade	Marked weakness, shallow breathing, apnea	Emergency response. Stop drug and provide airway/ventilatory support. This is more likely with myasthenia gravis, anesthesia, magnesium, or neuromuscular blockers.
Injection-site injury/infection	Severe pain, numbness, persistent swelling, redness, pus	Stop using that site, assess for nerve injury/abscess, document and notify prescriber. Rotate to an appropriate site.

Streptomycin is particularly associated with vestibular toxicity, while both auditory and vestibular dysfunction can occur. The current product safety information states that tinnitus, roaring sounds, or ear fullness should trigger audiometry and possible discontinuation.

When not to administer until reviewed

Hold the scheduled dose and contact the treating clinician if there is:

New tinnitus, vertigo, hearing change, or marked imbalance.
A meaningful rise in creatinine, fall in eGFR, oliguria, or acute dehydration.
Pregnancy discovered during treatment.
Severe rash or any suspected allergy.
New muscle weakness, dysphagia, or respiratory symptoms.
A new interacting nephrotoxic/ototoxic medicine.

The evidence supports combination treatment over several weeks for relapse prevention. A 2024 systematic review found some triple regimens including streptomycin had lower treatment failure and relapse than doxycycline-rifampicin alone, but the regimen must still be individualized for renal function and disease site in this systematic review.

For practical nursing use: screen daily for tinnitus, dizziness, hearing changes, urine reduction, and injection-site complications; check renal function at baseline and at least weekly; and hold the drug pending urgent prescriber review for any auditory, vestibular, renal, allergic, or respiratory toxicity.

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