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Debilitating Gentamicin Ototoxicity: Case Report and Recommendations Against Routine Use in Surgical Prophylaxis
Olivia A Kalmanson1, Kaitlin C McLoughlin2, Tyree H Kiser3
1Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA.
Introduction:
Aminoglycoside antibiotics such as gentamicin are bactericidal and effective against gram negative organisms and act synergistically against gram positive organisms, including Staphylococcus aureus. However, they have serious adverse effects such as nephrotoxicity and ototoxicity. Gentamicin ototoxicity may occur after a single dose and results in decreased vestibular function, which is frequently debilitating and often permanent.
Objective:
To emphasize the risk of gentamicin ototoxicity and suggest alternative antibiotics in penicillin-allergic patients undergoing surgery.
Case Summary:
We present a case of a woman with preexisting Meniere's Disease who received gentamicin 400 mg perioperatively for a sigmoidectomy due to a penicillin allergy listed in the patient's medical record. The patient developed severe ototoxicity preventing her from working or driving. Physical examination was remarkable for a broad-based gait requiring assistance to walk and bilateral corrective saccades. Vestibular testing revealed high-grade bilateral vestibular loss associated with all semicircular canals, a considerable decline compared to her function 3 years prior.
Discussion:
Gentamicin is indicated for surgical prophylaxis when a patient has a true allergy to penicillins and cannot receive cephalosporins, though alternatives exist. True allergies include IgE-mediated illness (anaphylaxis, bronchospasm, or urticaria 30-60 minutes after administration) or exfoliative reactions (Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis). The authors encourage more prudent use of gentamicin, especially in patients susceptible for debilitating otologic insults, and offer recommendations for alternative agents prior to using gentamicin.
Insights
Gentamicin can cause severe, permanent ototoxicity, even in patients with penicillin allergies. Alternative antibiotics should be considered to minimize risks, especially for those with pre-existing vestibular conditions.
Area of Science:
- Ototoxicity
- Antibiotic Stewardship
- Vestibular Dysfunction
Background:
- Aminoglycoside antibiotics like gentamicin are effective against Gram-negative and Gram-positive bacteria.
- Gentamicin carries significant risks, including nephrotoxicity and ototoxicity, which can lead to permanent vestibular dysfunction.
- Ototoxicity from gentamicin can occur even after a single dose.
Observation:
- A patient with Meniere's Disease received gentamicin for surgical prophylaxis due to a penicillin allergy.
- The patient experienced severe ototoxicity, impacting her ability to work and drive.
- Vestibular testing confirmed high-grade bilateral vestibular loss, significantly worse than previous assessments.
Findings:
- Gentamicin is indicated for surgical prophylaxis in penicillin-allergic patients when cephalosporins are contraindicated.
- True penicillin allergies include IgE-mediated reactions or severe exfoliative conditions.
- This case highlights the severe ototoxic risk of gentamicin, particularly in susceptible individuals.
Implications:
- Prudent use of gentamicin is recommended, especially in patients at risk for otologic damage.
- Alternative antibiotic agents should be prioritized over gentamicin when possible.
- Healthcare providers should carefully weigh the risks and benefits of gentamicin, considering patient history and alternative options.
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