Can streptomycin be administered safely and effectively through Intravenous (IV)?

Intravenous Streptomycin Administration

Yes, streptomycin can be safely and effectively administered intravenously, though intramuscular (IM) injection remains the FDA-approved and preferred route. 1

Evidence Supporting IV Administration

Guideline Recognition

• The American Heart Association explicitly recognizes IV streptomycin as an acceptable route in their 2015 endocarditis guidelines, stating streptomycin sulfate can be given "IV or IM in 2 equally divided doses" for enterococcal endocarditis treatment 1
• The CDC's 2021 plague treatment guidelines similarly acknowledge that "the IM formulation of streptomycin has been given intravenously as an off-label use" and cite supporting literature for this practice 1

Clinical Experience

• Case reports demonstrate successful IV use in critically ill patients where IM administration may be problematic due to hypoperfusion or poor muscle perfusion 2, 3
• Pharmacokinetic studies confirm adequate serum concentrations are achieved with IV administration, with population pharmacokinetics showing comparable drug exposure between IV and IM routes 1

Practical Considerations for IV Use

Administration Guidelines

• Administer via central venous catheter when possible to minimize phlebitis risk 2
• Infuse slowly over 30-60 minutes rather than IV push to reduce adverse reactions 1
• Standard dosing applies: 15 mg/kg/day (maximum 1 g/day) for adults, divided into 1-2 doses 1, 4

When IV Route is Particularly Useful

• Patients with poor peripheral perfusion (septic shock, hypotension) where IM absorption may be unreliable 2
• High-level gentamicin-resistant enterococcal endocarditis requiring streptomycin as the only effective aminoglycoside option 1, 2, 3
• Patients requiring multiple daily IM injections where muscle sites become limited or painful 3

Critical Safety Monitoring

Toxicity Surveillance

• Ototoxicity remains the primary concern regardless of administration route, with persistent hearing loss occurring in approximately 29% of adults receiving prolonged therapy 5
• Monitor renal function closely, though nephrotoxicity appears less common than with other aminoglycosides and is typically transient 4, 5
• Obtain baseline and serial audiometry, particularly for high-frequency hearing loss which is most affected 5

High-Risk Populations Requiring Extra Caution

• Adults over 59 years have significantly increased ototoxicity risk 4
• Pregnant women should avoid streptomycin due to documented fetal hearing loss risk 1, 4
• Patients with renal insufficiency require dose adjustment and more frequent monitoring 4
• Concomitant diuretic use substantially increases ototoxicity risk 4

Common Pitfalls to Avoid

• Do not assume IV administration eliminates toxicity—ototoxicity and nephrotoxicity risks persist with either route 5
• Avoid rapid IV push administration—this may cause adverse reactions and has not been adequately studied 1
• Do not use in pregnancy—streptomycin crosses the placenta and causes irreversible fetal eighth cranial nerve damage 1, 4
• Monitor peak and trough levels when available, targeting peak 20-35 μg/mL and trough <10 μg/mL 1