Polymyxin B-associated hearing impairment in a patient with renal dysfunction- a case report

Polymyxin B (PMB) is a polypeptide antibiotic primarily used to treat infections caused by multidrug-resistant gram-negative bacteria. Its main adverse effects are neurotoxicity and nephrotoxicity. Neurotoxicity may manifest as irritability, fatigue, lethargy, ataxia, dysgeusia, limb numbness, and blurred vision. Hearing impairment attributed to PMB is rarely reported. Herein, we describe a case of hearing impairment in a patient with renal dysfunction, potentially related to intravenous PMB therapy.

A 54-year-old, 70-kg male with poorly controlled type 2 diabetes (complicated by nephropathy, neuropathy, retinopathy), end-stage kidney disease (on hemodialysis), and hypertension was admitted to the ICU for gastrointestinal bleeding and hemorrhagic shock. On postoperative day 7, he developed carbapenem-resistant Acinetobacter baumannii (CR-AB) pneumonia and was treated with PMB 50 mg q12h plus sulbactam 2 g q8h. Therapeutic drug monitoring (TDM) showed the area under the plasma concentration-time curve across 24 h at steady state (AUC_{ss, 24 h}) of PMB was 37.7 mg·h/L. PMB was increased to 100 mg q12h, after which the patient reported hearing impairment, with a corresponding AUC_{ss, 24 h} of 152.8 mg·h/L. The dose was then reduced and subsequently discontinued. The patient's hearing fully recovered one day after discontinuation. No formal audiologic testing was performed; the diagnosis relied on patient self-report and clinical observation.

This case highlights the importance of recognizing neurotoxic events related to PMB, including hearing impairment. Close monitoring and timely intervention are especially critical in patients with renal insufficiency or those receiving high-dose PMB. Accordingly, TDM plays an important role in anticipating and avoiding such adverse reactions.