title: Misleading high tobramycin plasma concentrations can be caused by skin contamination of fingerprick blood following inhalation of nebulized tobramycin (TOBI): a short report.
abstract: We observed unexpected high plasma concentrations of tobramycin (48.5 and 28.1 mg/L) in fingerprick blood samples after the nebulization of tobramycin solution for inhalation (tobramycin 300 mg/5 mL, TOBI by 2 young children aged 3 years. To investigate whether dermal contamination could be the source of error, 3 adult volunteers were present during another nebulization by a third child (age 2 years). The volunteers had exposure to tobramycin by handling the nebulizer or the nebule and also by inhalation from holding the child and being in close proximity while TOBI was being administered. Five blood samples by fingerprick and 2 by venipuncture were collected and assayed for tobramycin concentration. On each occasion the site was swabbed with alcohol wipes to mimic standard patient sampling methods. One site was resampled after cleaning of hands with 2% chlorhexidine gluconate and water. Tobramycin concentrations from venipuncture 1-2 hours after nebulization were all <0.2 mg/L except for 1 result of 1.2 mg/L. The tobramycin concentrations from fingerpricks before hand washing varied between 6.8 and 172 mg/L, and after hand washing between 0.3 and 17.6 mg/L. Contamination of fingers with tobramycin is likely to have caused the error in the 2 initial cases and did cause misleadingly elevated levels in the adult volunteers. We caution that therapeutic drug monitoring of nebulized tobramycin should not be done by fingerprick sampling, and care should be taken to avoid contamination of the venipuncture site.
authors.affiliation: School of Pharmacy, The University of Queensland, Brisbane, Queensland 4072, Australia. s4045326@student.uq.edu.au
authors.forename: Stefanie
authors.initials: S
authors.lastname: Redmann
authors.forename: Claire
authors.initials: C
authors.lastname: Wainwright
authors.forename: Sonya
authors.initials: S
authors.lastname: Stacey
authors.forename: Anita
authors.initials: A
authors.lastname: Champion
authors.forename: Penny
authors.initials: P
authors.lastname: Mitchell
authors.forename: Joyce
authors.initials: J
authors.lastname: Cheney
authors.forename: Bruce
authors.initials: B
authors.lastname: Charles
mesh_terms: D002675:Child, Preschool; D004340:Drug Contamination; D005189:False Positive Reactions; D005260:Female; D005385:Fingers / Q000098:blood supply; D006801:Humans; D001239:Inhalation / Q000187:drug effects / Q000502:physiology*; D008297:Male; D009330:Nebulizers and Vaporizers / Q000706:statistics & numerical data; D018962:Phlebotomy / Q000379:methods*; D012867:Skin / Q000737:chemistry* / Q000187:drug effects / Q000378:metabolism; D012869:Skin Absorption / Q000187:drug effects / Q000502:physiology; D014031:Tobramycin / Q000008:administration & dosage / Q000097:blood* / Q000493:pharmacokinetics
chemical_list: D014031:Tobramycin