Neomycin Sulfate

Class: Aminoglycosides
VA Class: AM300
CAS Number: 1405-10-3
Brands: Neo-Fradin, Neo-Rx

• Neurotoxicity and Ototoxicity


• 
  

  Neurotoxicity (manifested as both auditory and vestibular ototoxicity) can occur, even at recommended doses.^{1 2}

  
  


• 
  

  Risk of eighth-cranial nerve impairment is increased in patients with preexisting renal damage and in those with normal renal function who receive doses higher or treatment longer than recommended.^{1 2}

  
  


• 
  

  Aminoglycoside-induced ototoxicity is irreversible, usually bilateral, and may be partial or total.^{1 2}

  
  


• 
  

  Patients developing cochlear damage may not have symptoms during aminoglycoside treatment to warn them of eighth-cranial nerve toxicity and total or partial, irreversible, bilateral deafness may occur after drug discontinued.^{1 2}

  
  

• Nephrotoxicity


• 
  

  Potentially nephrotoxic, even at recommended doses.^{1 2}

  
  


• 
  

  Nephrotoxicity develops principally in patients with preexisting renal damage and in those with normal renal function who receive doses higher or treatment longer than recommended.^{1 2}

  
  

• Patient Monitoring


• 
  

  Patients should be under close clinical observation because of potential toxicities.^{1 2}

  
  


• 
  

  Oral neomycin is absorbed systemically; toxic reactions may occur.^{1 2}

  
  


• 
  

  Closely monitor renal and eighth-cranial nerve function.^{1 2} Perform serial, vestibular, and audiometric tests and tests of renal function, particularly in high-risk patients.^{1 2}

  
  


• 
  

  Advanced age and dehydration may increase risk of toxicity.^{1 2}

  
  

• Neuromuscular Blockade


• 
  

  Neuromuscular blockage and respiratory paralysis reported with oral neomycin.^{1 2}

  
  


• 
  

  Concomitant use of an aminoglycoside with anesthesia and muscle-relaxing drugs may cause neuromuscular blockade with respiratory paralysis.^{1 2}

  
  


• 
  

  Consider possibility of neuromuscular blockade and respiratory paralysis when administering aminoglycosides, especially if used concurrently with anesthetics or neuromuscular-blocking agents (e.g., tubocurarine, succinylcholine, decamethonium) or in patients receiving massive transfusions of citrate-anticoagulated blood.^{1 2} (See Specific Drugs under Interactions.)

  
  


• 
  

  Calcium salts may reduce manifestations if blockade occurs; may require mechanical respiratory assistance.^{1 2}

  
  

• Interactions


• 
  

  Avoid concurrent and/or sequential use of other systemic, topical, or oral neurotoxic or nephrotoxic drugs, particularly other aminoglycosides (including paromomycin), amphotericin B, bacitracin, cisplatin, colistin, polymyxin B, vancomycin, and viomycin (not commercially available in the US).^{1 2} (See Interactions.)

  
  


• 
  

  Avoid concurrent use of potent diuretics (e.g., ethacrynic acid, furosemide) since diuretics themselves may cause ototoxicity and IV diuretics enhance toxicity by altering serum and tissue aminoglycoside concentrations.^{1 2} (See Interactions.)

  
  

Introduction

Antibacterial; aminoglycoside antibiotic obtained from cultures of Streptomyces fradiae.^{1 2 14 23}

Uses for Neomycin Sulfate

Hepatic Encephalopathy

Management of hepatic encephalopathy.^{1 2 11 13 26 27 28} Used to inhibit ammonia-forming bacteria in the GI tract in patients with hepatic (portal-systemic) encephalopathy as an adjunct to protein restriction and supportive therapy.^{1 2 11 13 26 27 28} Subsequent reduction in blood ammonia may result in neurologic improvement.^{1 2 11 27}

Although efficacy of such adjunctive treatment is not clearly established,¹² it has been suggested that nonabsorbable disaccharides (lactulose) are first-line treatment to reduce blood ammonia in adults with acute hepatic encephalopathy and anti-infectives (e.g., oral neomycin or metronidazole) are alternatives.^{11 28}

Perioperative Prophylaxis

Adjunct to mechanical cleansing of the large intestines for preoperative prophylaxis in patients undergoing colorectal surgery.^{2 3 6 13} Used in conjunction with oral erythromycin or oral metronidazole and with an appropriate diet and catharsis.^{2 3 6}

Preferred regimens for patients undergoing colorectal surgery are IV cefoxitin or IV cefotetan alone; IV cefazolin and IV metronidazole; oral erythromycin and oral neomycin; or oral metronidazole and oral neomycin.^{3 6}

Hypercholesterolemia

Treatment of hypercholesterolemia†.^{13 16 17 20 25} Therapeutic value may be due in part to reduction in GI absorption of cholesterol, resulting in enhanced elimination of cholesterol as neutral sterols in the feces.^{13 16 20}

Not a first- or second-line agent; use only after all conventional treatments have been tried.^{18 25}

GI Infections

Not recommended for treatment of any GI infections†.¹³

Neomycin Sulfate Dosage and Administration

Administration

Oral Administration

Administer orally.^{1 2}

Dosage

Available as neomycin sulfate; dosage expressed in terms of the sulfate.^a

To minimize risk of toxicity, use lowest possible dosage and shortest duration of therapy.^{1 2} Closely monitor patients for aminoglycoside toxicity, especially when used for adjunctive treatment of chronic hepatic insufficiency.^{1 2 11}

Treatment duration >2 weeks is not recommended.^{1 2} Weigh risks of nephrotoxicity, permanent ototoxicity, and neuromuscular blockade against benefits of prolonged treatment.¹ If treatment is prolonged, closely monitor serum neomycin concentrations and renal, auditory, and vestibular functions.¹

Individualize dosage taking into consideration the patient's pretreatment body weight, renal status, and serum concentrations of the drug.^b Because of potential toxicity, fixed-dosage recommendations that are not based on patient weight or serum drug concentrations are not advised.^b

Pediatric Patients

General Pediatric Dosage

Oral

Neonates ≤1 month of age†: AAP recommends 25 mg/kg every 6 hours.⁵

Infants and children >1 month of age†: AAP recommends 100 mg/kg daily given in 4 equally divided doses.⁵

Manufacturers state that if neomycin is considered necessary in children <18 years of age†, duration of therapy should not exceed 2 weeks^{1 2} . (See Pediatric Use under Cautions.)

Hepatic Encephalopathy

Oral

Children†: 100 mg/kg daily given in 4 divided doses for ≤7 days.²⁷

Prior to initiation of neomycin, withdraw protein from the diet and avoid diuretics; incrementally return protein back to the diet during treatment.^{1 2} Monitor closely;^{1 2 11} give supportive therapy (including blood products) as indicated.^{1 2}

Adults

Hepatic Encephalopathy

Oral

Hepatic coma: 4–12 g daily given in divided doses (e.g., 4 doses daily) for 5–6 days recommended by the manufacturers and others.^{1 2 26 28}

Chronic hepatic insufficiency when less toxic drugs cannot be used: Up to 4 g daily recommended by the manufacturers.^{1 2}

Some clinicians recommend 3–6 g daily for 1–2 weeks for acute encephalopathy¹¹ and 1–2 g daily for chronic encephalopathy.¹¹

Prior to initiation of neomycin, withdraw protein from the diet and avoid diuretics; incrementally return protein back to the diet during treatment.^{1 2} Monitor closely;^{1 2 11} give supportive therapy (including blood products) as indicated.^{1 2}

Perioperative Prophylaxis

Adjunct to Mechanical Cleansing in Patients Undergoing Colorectal Surgery

Oral

For 8 a.m. surgery: Give 1 g neomycin sulfate and 1 g erythromycin base at 1 p.m., 2 p.m., and 11 p.m. on the day preceding surgery.^{2 3 6} Alternatively, give 2 g neomycin sulfate and 2 g metronidazole at 7 p.m. and 11 p.m. on the day preceding surgery.³

Begin a minimum residue or clear liquid diet 1–3 days before colorectal surgery with appropriate catharsis.^{2 3 6}

Hypercholesterolemia†

Oral

0.5–2 g daily.^{16 25} Do not use for long-term treatment.¹³

Prescribing Limits

Adults

Hepatic Encephalopathy

Chronic Hepatic Encephalopathy

Oral

Maximum: 4 g daily.^{1 2}

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time other than those for patients with hepatic encephalopathy.^{1 2 a}

Renal Impairment

Reduce dosage or discontinue drug in patients with renal impairment.¹

Some clinicians recommend that doses be given every 6 hours in those with GFR >50 mL/minute, every 12–18 hours in those with GFR 10–50 mL/minute, or every 18–24 hours in those with GFR <10 mL/minute.²⁴

Geriatric Patients

Select dosage with caution and closely monitor renal function because of age-related decreases in renal function.^{1 2}

Cautions for Neomycin Sulfate

Contraindications

• 
  

  History of hypersensitivity or serious toxic reactions to neomycin or other aminoglycosides.^{1 2}

  
  


• 
  

  Intestinal obstruction.^{1 2}

  
  


• 
  

  Inflammatory or ulcerative GI disease; may enhance GI absorption of neomycin.^{1 2}

  
  

Warnings/Precautions

Warnings

Neurotoxicity and Ototoxicity

Patients receiving aminoglycosides should be under close clinical observation because of possible ototoxicity.^{1 2}

Vestibular and permanent bilateral auditory ototoxicity occurs most frequently in those with past or present history of renal impairment, those receiving other ototoxic drugs, and those who receive high dosages or prolonged treatment.^{1 2}

Perform serial, vestibular, and audiometric tests, if feasible, in patients old enough to be tested, particularly in high-risk patients.^{1 2}

Perform tests of the vestibulocochlearis nerve (eighth cranial nerve) function prior to and periodically during neomycin therapy.^{1 2}

Numbness, skin tingling, muscle twitching, and convulsions also may be signs of neurotoxicity.^{1 2}

Risk of hearing loss continues after drug withdrawal.^{1 2}

Some aminoglycosides have caused fetal ototoxicity when administered to pregnant women.^{1 2} (See Pregnancy under Cautions.)

Nephrotoxicity

Patients receiving aminoglycosides should be under close clinical observation because of possible nephrotoxicity.^{1 2} Renal function should be assessed prior to therapy and daily, or more frequently, during therapy.^{1 2}

Nephrotoxicity occurs most frequently in those with past or present history of renal impairment, those receiving other nephrotoxic drugs, and those who receive high dosage or prolonged treatment.^{1 2}

Monitor urine for increased protein excretion, decreased specific gravity, and the presence of cells and casts.^{1 2} Obtain Cl_cr, S_cr, and/or BUN at the onset of therapy and periodically during therapy.^{1 2}

Decrease dosage or discontinue drug if renal insufficiency develops.^{1 2}

Neuromuscular Blockade

Neuromuscular blockade and respiratory paralysis reported following oral neomycin.^{1 2}

Possibility of neuromuscular blockade should be considered, especially in patients receiving anesthetics or neuromuscular blocking agents (e.g., tubocurarine, succinylcholine, decamethonium) or in those receiving massive transfusions of citrate-anticoagulated blood.^{1 2}

Calcium salts may reverse neuromuscular blockade, but mechanical respiratory assistance may be necessary.^{1 2}

Sensitivity Reactions

Hypersensitivity

Serious and occasionally fatal hypersensitivity reactions, including anaphylaxis, reported with aminoglycosides.

Cross-sensitivity

Cross-sensitivity occurs among the aminoglycosides.^{1 2}

General Precautions

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of neomycin and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.²

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.² In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.²

Topical Instillation

Quickly and almost totally absorbed from body surfaces (except the urinary bladder) after local irrigation or intraoperative topical application in association with medical procedures; neurotoxicity, nephrotoxicity, neuromuscular blockade, or respiratory paralysis may occur, even with minute quantities of neomycin, regardless of renal function.^{1 2}

Neuromuscular Disorders

Use with caution in patients with neuromuscular disorders such as myasthenia gravis or parkinsonism; may aggravate muscle weakness because of potential curare-like effect on the neuromuscular junction.^{1 2}

Superinfection

Possible emergence and overgrowth of nonsusceptible bacteria or fungi.^{1 2} Institute appropriate therapy if superinfection occurs.^{1 2}

Malabsorption Syndrome

May produce a malabsorption syndrome for a variety of substances including fat, nitrogen, cholesterol, carotene, glucose, xylose, lactose, sodium, calcium, cyanocobalamin, and iron.^{1 2} Usually reversible and dose-related; occurs most frequently in prolonged therapy or at high dosage (i.e., 12 g daily).^{1 2 13 23}

Specific Populations

Pregnancy

Category D.^{1 2}

Possibility of fetal harm if administered to a pregnant woman.^{1 2} Complete, irreversible, bilateral congenital deafness reported when another aminoglycoside (i.e., streptomycin) was used during pregnancy.^{1 2}

Lactation

IM neomycin is distributed into milk in cows; not known whether distributed into human milk.^{1 2} Discontinue nursing or the drug.^{1 2}

Pediatric Use

Safety and efficacy not established in children <18 years of age.^{1 2}

If neomycin is considered necessary in children <18 years of age†, use with caution ^{1 2} and do not treat for >2 weeks^{1 2} since GI absorption may occur.^{1 2}

Risk of toxicity is increased in premature infants and neonates†.^{1 2}

Geriatric Use

Increased risk of toxicity; use with caution and closely monitor renal function.^{1 2}

When assessing renal function in geriatric patients, Cl_cr may be more useful than BUN or S_cr.^{1 2}

Renal Impairment

Patients with renal impairment are at higher risk of nephrotoxicity and ototoxicity.^{1 2}

Patients with renal insufficiency may develop toxic blood concentrations unless doses are properly regulated.^{1 2}

Common Adverse Effects

Nausea,^{1 2} vomiting,^{1 2} diarrhea,^{1 2} abdominal cramps.^{13 23}

Interactions for Neomycin Sulfate

Neurotoxic, Ototoxic, or Nephrotoxic Drugs

Concomitant or sequential use with other drugs that have neurotoxic, ototoxic, or nephrotoxic effects may result in additive toxicity and should be avoided, if possible.^{1 2}

Because of the possibility of an increased risk of ototoxicity due to additive effects or altered serum and tissue aminoglycoside concentrations, do not use concurrently with potent diuretics.^{1 2}

Specific Drugs

Drug	Interaction	Comments
Aminoglycosides	Concurrent or serial use may enhance nephrotoxicity, ototoxicity, and/or potentiate neuromuscular blockade1 2	Avoid concurrent or sequential use, if possible1 2
Amphotericin B	Possible increased incidence of nephrotoxicity and/or neurotoxicity1 2	Avoid concurrent or sequential use, if possible1 2
Anticoagulants, oral	Neomycin may enhance warfarin effects by decreasing vitamin K availability1 2	Monitor prothrombin time; adjust warfarin dosage as requiredb
Anti-emetics (e.g., dimenhydrinate, meclizine)	Anti-emetics that suppress nausea and vomiting of vestibular origin and vertigo may mask symptoms of vestibular ototoxicity23
Bacitracin	Possible increased incidence of nephrotoxicity and/or neurotoxicity1 2	Avoid concurrent or sequential use, if possible1 2
β-Lactam antibiotics (cephalosporins, penicillins)	Possible increased incidence of nephrotoxicity reported with some cephalosporins; cephalosporins may spuriously elevate creatinine concentrationsb Potential in vitro and in vivo inactivation of aminoglycosidesb	Monitor serum aminoglycoside concentrations, especially when high penicillin doses are used or patient has renal impairmentb
Cisplatin	Possible increased incidence of nephrotoxicity and/or neurotoxicity1 2	Avoid concurrent or sequential use, if possible1 2
Colistimethate/Colistin	Possible increased incidence of nephrotoxicity and/or neurotoxicity1 2	Avoid concurrent or sequential use, if possible1 2
Cyanocobalamin (vitamin B12)	Neomycin inhibits GI absorption of oral vitamin B121 2	Clinical importance unclearb
Digoxin	Neomycin inhibits GI absorption of digoxin1 2	Monitor digoxin serum concentrations1 2
Diuretics (ethacrynic acid, furosemide)	Possible increased risk of ototoxicity (diuretics themselves may cause ototoxicity) or increased risk of other aminoglycoside-related adverse effects (diuretics may alter aminoglycoside serum or tissue concentrations)1 2
5-Fluorouracil	Neomycin inhibits GI absorption of 5-fluorouracil1 2	Clinical importance unclearb
Methotrexate	Neomycin inhibits GI absorption of methotrexate1 2	Clinical importance unclearb
Neuromuscular blocking agents and general anesthetics (succinylcholine, tubocurarine, decamethonium)	Possible potentiation of neuromuscular blockade and respiratory paralysis1 2	Use concomitantly with caution; observe closely for signs of respiratory depression1 2
NSAIAs	Possible increased serum aminoglycoside concentrations reported with indomethacin in premature neonates; may be related to indomethacin-induced decreases in urine output	Closely monitor aminoglycoside concentrations and adjust dosage accordingly
Penicillin V	Neomycin inhibits GI absorption of penicillin V1 2	Clinical importance unclearb
Polymyxins	Possible increased incidence of nephrotoxicity and/or neurotoxicity; possible potentiation of neuromuscular blockade1 2	Avoid concurrent or sequential use, if possible1 2
Vancomycin	Possible increased incidence of nephrotoxicity and/or neurotoxicity1 2	Avoid concurrent or sequential use, if possible1 2

Neomycin Sulfate Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract;^{26 29} about 3% of an oral dose is absorbed.^{1 2 21 22} Damaged or inflamed mucosa may increase GI absorption.²⁹

Rapidly and almost totally absorbed from body surfaces (except the urinary bladder) after local irrigation or intraoperative topical application in association with medical procedures.^{1 2}

Plasma Concentrations

In adults, a single 4-g oral dose produced peak plasma concentrations of 2.5–6.1 mcg/mL at 1–4 hours after the dose.²¹

Distribution

Extent

Distributed in low concentrations in intestinal wall and muscles.¹⁹

Distributed into milk in animals; not known whether distributed into human milk.^{1 2}

Plasma Protein Binding

0–30%.^{1 2}

Elimination

Elimination Route

Excreted principally in feces (97%) as unchanged drug^{1 2 13 26} and in urine (1%).^{13 21 22}

Removed by hemodialysis.^{1 2}

Half-life

Adults with normal renal function: 2–3 hours.^{23 24 29}

Severe renal impairment: 12–24 hours.²⁴

Stability

Storage

Oral

Tablets

20–25°C in tight container.²

Oral Solution

15–30°C.¹

Actions and SpectrumActions

• 
  

  Usually bactericidal.^{1 2 b}

  
  


• 
  

  Inhibits protein synthesis in susceptible bacteria by irreversibly binding to 30S ribosomal subunits.^b

  
  


• 
  

  Following oral administration, rapidly suppresses growth of most intestinal bacteria; these are replaced by nonpathogenic yeasts and, occasionally, resistant strains of Enterobacter aerogenes.^{1 2} Suppression persists for 48–72 hours after the dose.^{1 2}

  
  


• 
  

  In vitro spectrum of activity includes many gram-negative aerobic bacteria and some aerobic gram-positive bacteria.^{1 2} Inactive against fungi,^b viruses,^b and most anaerobic bacteria.^{1 2 b}

  
  


• 
  

  Gram-negative aerobes: Active in vitro against Enterobacter, Escherichia coli, and Klebsiella.^{1 2}

  
  


• 
  

  Partial cross-resistance occurs between neomycin and other aminoglycosides.^b

  
  

Advice to Patients

• 
  

  Advise patients that antibacterials (including neomycin) should only be used to treat bacterial infections and not be used to treat viral infections (e.g., the common cold).²

  
  


• 
  

  Importance of completing full course of therapy, even if feeling better after a few days.²

  
  


• 
  

  Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with neomycin or other antibacterials in the future.²

  
  


• 
  

  Advise patients of the risk of toxic effects on the eighth nerve, including partial or total deafness.^{1 2} Inform patients that the possibility of acute toxicity is increased in premature infants and neonates.^{1 2}

  
  


• 
  

  Importance of informing clinician if there is evidence of ototoxicity (dizziness, vertigo, tinnitus, roaring in the ears, hearing loss), other neurotoxicity (numbness, skin tingling, muscle twitching, seizures), or nephrotoxicity (e.g., decreased urine output).^{1 2}

  
  


• 
  

  Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.^{1 2}

  
  


• 
  

  Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{1 2}

  
  


• 
  

  Importance of advising patients of other important precautionary information.^{1 2} (See Cautions.)

  
  

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Neomycin Sulfate

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Bulk	Powder*		Neo-Rx Powder	X-Gen
Oral	Solution	125 mg (87.5 mg of neomycin) per 5 mL	Neo-Fradin	X-Gen
	Tablets	500 mg (350 mg of neomycin)*	Neomycin Sulfate Tablets (with povidone)	Teva

Disclaimer

This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.

The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.

AHFS Drug Information. © Copyright, 1959-2011, Selected Revisions January 01, 2008. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

1. Pharma-Tek Inc. Neo-Fradin (neomycin sulfate) oral solution prescribing information. Huntington, NY. 2002 Jul.

2. Teva. Neomycin sulfate tablets USP prescribing information. Sellersville, PA. 2003 Mar.

3. Anon. Antimicrobial prophylaxis for surgery. Med Lett Treat Guid. 2004; 2:27-32.

4. Nichols RL, Smith JW, Garcia RY et al. Current practices of preoperative bowel preparation among North American colorectal surgeons. Clin Infect Dis. 1997; 24:609-19. [IDIS 384359] [PubMed 9145734]

5. American Academy of Pediatrics. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:751, 753.

6. Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers Workgroup. antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Clin Infect Dis. 2004; 38:1706-15. [PubMed 15227616]

7. Schoetz DJ, Roberts PL, Murray JJ et al. Addition of parenteral cefoxitin to regimen of oral antibiotics for elective colorectal operations. Ann Surg. 1990; 212:209-12. [IDIS 269407] [PubMed 2100983]

8. Espin-Basany E, Sanchez-Garcia JL, Lopez-Cano M et al. Prospective, randomized study on antibiotic prophylaxis in colorectal surgery. Is it really necessary to use oral antibiotics? Int J Colorectal Dis. 2005; 20:542-6.

9. Wren SM, Ahmed N, Jamal A et al. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surg. 2005; 140:752-6. [PubMed 16103284]

10. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg. 2002; 45:173-80. [PubMed 12067168]

11. Blei AT, Cordoba J, the Practice Parameters Committee of the American College of Gastroenterology. Hepatic encephalopathy. Am J Gastroenterol. 2001; 96:1968-76. [PubMed 11467622]

12. Als-Nielsen B, Gluud LL, Gluud C. Nonabsorbable disaccharides for hepatic encephalopathy (review). Cochrane Database Syst Rev. 2004; 2:CD003044.

13. Kucers A, Crowe S, Grayson ML et al, eds. The use of antibiotics. A clinical review of antibacterial, antifungal, and antiviral drugs. 5th ed. Jordan Hill, Oxford: Butterworth-Heinemann; 1997: 533-41.

14. The United States pharmacopoeia, 29th rev, and The national formulary, 24th ed. Rockville, MD: The United States Pharmacopeial Convention; 2005:1491-3,3217.

15. Nelson JD. Duration of neomycin for enteropathogenic Escherichia coli diarrheal disease: a comparative study of 113 cases. Pediatrics. 1971; 48:248-58. [PubMed 5560618]

16. Samuel P. Treatment of hypercholesterolemia with neomycin–a time for reappraisal. N Engl J Med. 1979; 301:595-7. [PubMed 381924]

17. Gylling H, Miettinen TA. The effect of cholesterol absorption inhibition on low density lipoprotein cholesterol level. Atherosclerosis. 1995; 117:305-8. [PubMed 8801876]

18. Meisel S, Rate R. Neomycin for hypercholesterolemia. N Engl J Med. 1980; 302:233. [PubMed 7350468]

19. DiPiro JT, Patrias JM, Townsend RJ et al. Oral neomycin sulfate and erythromycin base before colon surgery: a comparison of serum and tissue concentrations. Pharmacotherapy. 1985; 5:91-4. [PubMed 4000983]

20. Sedaghat A, Samuel P, Crouse JR et al. Effects of neomycin on absorption, synthesis, and/or flux of cholesterol in man. J Clin Invest. 1975; 55:12-21. [PubMed 1109175]

21. Kunin CM, Chalmers TC, Leevy CM et al. Absorption of orally administered neomycin and kanamycin with special reference to patients with severe hepatic and renal disease. N Engl J Med. 1960; 262:380-5. [PubMed 14412744]

22. Breen KJ, Bryant RE, Levinson JD et al. Neomycin absorption in man. Studies of oral and enema administration and effect of intestinal ulceration. Ann Intern Med. 1972; 76:211-8. [PubMed 5009591]

23. Barza M, Scheife RT. Drug therapy reviews: antimicrobial spectrum, pharmacology and therapeutic use of antibiotics, part 4: aminoglycosides. Am J Hosp Pharm. 1977; 34:723-37. [PubMed 407790]

24. Bennett WM, Muther RS, Parker RA et al. Drug therapy in renal failure: dosing guidelines for adults. Ann Intern Med. 1980; 93:62-89. [IDIS 122057] [PubMed 6994534]

25. Hritcko P, Kapadia VK, Folstad J. Treatment of hypercholesterolemia with oral neomycin. AJHP. 1999; 56:2227-9. [PubMed 10565703]

26. Chambers HF. Aminoglycosides. In: Brunton LL, Lazo JS, Parker KL et al, eds. Goodman and Gillman’s the pharmacological basis of therapeutics. 11th ed. New York, NY: McGraw-Hill; 2006:1155-71.

27. Debray D, Yousef N, Durand P. New management options for end-stage chronic liver disease and acute liver failure. Pediatr Drugs. 2006; 8:1-13.

28. Harrison’s principles of internal medicine. 16th ed. Kasper DL, Braunwald E, Fauci AS et al, eds. New York: McGraw-Hill; 2006.

29. Sweetman S, ed. Martindale: the complete drug reference. London: Pharmaceutical Press. Electronic version. 2006.

a. AHFS drug information 2007. McEvoy GK, ed. Neomycin. Bethesda, MD: American Society of Health-System Pharmacists; 2007:80-81.

b. AHFS drug information 2007. McEvoy GK, ed. Aminoglycosides general statement. Bethesda, MD: American Society of Health-System Pharmacists; 2007:60-69.

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