Connect
MJA
MJA

Gentamicin ototoxicity: a 23-year selected case series of 103 patients

Rebekah M Ahmed, Imelda P Hannigan, Hamish G MacDougall, Raymond C Chan and G Michael Halmagyi
Med J Aust 2012; 196 (11): 701-704. || doi: 10.5694/mja11.10850

Summary

Objective: To review patients with severe bilateral vestibular loss associated with gentamicin treatment in hospital.

Design and setting: A retrospective case series of presentations to a balance disorders clinic between 1988 and 2010.

Main outcome measures: Relationship between vestibulotoxicity and gentamicin dose or dosing profile; indications for prescribing gentamicin.

Results: 103 patients (age, 18–84 years; mean, 64 years) presented with imbalance, oscillopsia or both, but none had vertigo. Only three noted some hearing impairment after having gentamicin, but audiometric thresholds for all patients were consistent with their age. In all patients, the following tests gave positive results: a bilateral clinical head-impulse test, a vertical head-shaking test for vertical oscillopsia, and a foam Romberg test. In 21 patients, imbalance occurred during gentamicin treatment (ignored or dismissed by prescribers in 20) and in 66 after treatment; the remaining 16 could not recall when symptoms were first noticed, except that it was after gentamicin treatment in hospital. Total gentamicin dose range was 2–318 mg/kg (mean, 52 mg/kg), daily dose range was 1.5–5.6 mg/kg (mean, 3.5 mg/kg), and duration was 1–80 days (mean, 17 days). Six patients had only a single dose; 26 had five or fewer doses. Serum gentamicin levels, measured in 82 patients, were in the recommended range in 59. Time to diagnosis ranged from 4 days to 15 years. Nephrotoxicity developed in 43 patients. Gentamicin dosage complied with contemporary or current Australian antibiotic guidelines in under half the patients.

Conclusions: Gentamicin ototoxicity is vestibular, not cochlear, producing permanent loss of balance, but not of hearing. Gentamicin can be vestibulotoxic in any dose, in any regimen, at any serum level.

  • Rebekah M Ahmed1
  • Imelda P Hannigan1
  • Hamish G MacDougall2
  • Raymond C Chan1
  • G Michael Halmagyi1

  • 1 Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW.
  • 2 Vestibular Research Laboratory, School of Psychology, University of Sydney, Sydney, NSW.

Correspondence: michael@icn.usyd.edu.au

Acknowledgements: 

We thank Dr Richard Benn for helpful discussions over many years and Dr Vicki Levidiotis for reviewing the manuscript. The study was supported by Garnett Passe and Rodney Williams Memorial Foundation (Hamish MacDougall) and National Health and Medical Research Council Grant 245515 (Michael Halmagyi).

Competing interests:

Michael Halmagyi and Hamish MacDougall have acted as unpaid consultants for GN Otometrics.

  • 1. Dobie RA, Black FO, Pezsnecker SC, Stallings VL. Hearing loss in patients with vestibulotoxic reactions to gentamicin therapy. Arch Otolaryngol Head Neck Surg 2006; 132: 253-257.
  • 2. Seemungal BM, Bronstein AM. Aminoglycoside ototoxicity: vestibular function is also vulnerable. BMJ 2007; 335: 952.
  • 3. Halmagyi GM, Fattore CM, Curthoys IS, Wade S. Gentamicin vestibulotoxicity. Otolaryngol Head Neck Surg 1994; 111: 571-574.
  • 4. Black FO, Pesznecker S, Stallings V. Permanent gentamicin vestibulotoxicity. Otol Neurotol 2004; 25: 559-569.
  • 5. Ishiyama G, Ishiyama A, Kerber K, Baloh RW. Gentamicin ototoxicity: clinical features and the effect on the human vestibulo-ocular reflex. Acta Otolaryngol 2006; 126: 1057-1061.
  • 6. Ariano RE, Zelenitsky SA, Kassum D. Aminoglycoside-induced vestibular injury: maintaining a sense of balance. Ann Pharmacother 2008; 42: 1282-1289.
  • 7. Minor LB. Gentamicin-induced bilateral vestibular hypofunction. JAMA 1998; 279: 541-544.
  • 8. Zingler VC, Cnyrim C, Jahn K, et al. Causative factors and epidemiology of bilateral vestibulopathy in 255 patients. Ann Neurol 2007; 61: 524-532.
  • 9. Weber KP, Aw ST, Todd MJ, et al. Horizontal head impulse test detects gentamicin vestibulotoxicity. Neurology 2009; 72: 1417-1424.
  • 10. Vital D, Hegemann SC, Straumann D, et al. A new dynamic visual acuity test to assess peripheral vestibular function. Arch Otolaryngol Head Neck Surg 2010; 136: 686-691.
  • 11. Vereeck L, Truijen S, Wuyts FL, Van de Heyning PH. The dizziness handicap inventory and its relationship with functional balance performance. Otol Neurotol 2007; 28: 87-93.
  • 12. Halmagyi GM, Yavor RA, McGarvie LA. Testing the vestibulo-ocular reflex. Adv Otorhinolaryngol 1997; 53: 132-154.
  • 13. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010.
  • 14. Herdman SJ. Vestibular rehabilitation. 3rd ed. New York: Davis, 2007: 309-359.
  • 15. Gates, GA, Cooper JC, Kannel WB, Miller NJ. Hearing in the elderly: the Framingham cohort, 1983-1985. Part I. Basic audiometric test results. Ear Hear 1990; 11: 247-256.
  • 16. Pearson JD, Morrell CH, Gordon-Salant S, et al. Gender differences in a longitudinal study of age-associated hearing loss. J Acoust Soc Am 1995; 97: 1196-1205.
  • 17. Sha SH, Qiu JH, Schacht J. Aspirin to prevent gentamicin-induced hearing loss. N Engl J Med 2006; 354: 1856-1857.
  • 18. Moore RD, Smith CR, Lietman PS. Risk factors for the development of auditory toxicity in patients receiving aminoglycosides. J Infect Dis 1984; 149: 23-30.
  • 19. Lancaster JL, Mortimore S, McCormick M, Hart CA. Systemic absorption of gentamicin in the management of active mucosal chronic otitis media. Clin Otolaryngol Allied Sci 1999; 24: 435-439.
  • 20. Stavroulaki P, Apostolopoulos N, Dinopoulou D, et al. Otoacoustic emissions – an approach for monitoring aminoglycoside induced ototoxicity in children. Int J Pediatr Otorhinolaryngol 1999; 50: 177-184.
  • 21. JC. Living without a balancing mechanism. N Engl J Med 1952; 246: 458-460.
  • 22. MacDougall HG, Weber KP, McGarvie LA, et al. The video head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology 2009; 73: 1134-1141.
  • 23. Gentamicin Information Center. About gentamicin poisoning. http://www.gentamicin.com (accessed Mar 2012).
  • 24. Appel GB. Aminoglycoside nephrotoxicity. Am J Med 1990; 88: 16S-20S.
  • 25. Prins JM, Buller HR, Kuijper EJ, et al. Once versus thrice daily gentamicin in patients with serious infections. Lancet 1993; 341: 335-339.
  • 26. Raveh D, Koypt M, Hite Y, et al. Risk factors for nephrotoxicity in elderly patients receiving once-daily aminoglycosides. QJM 2002; 95: 291-297.
  • 27. English WP, Williams MD. Should aminoglycoside antibiotics be abandoned? Am J Surg. 2000; 180: 512-515.
  • 28. Leong CL, Buising K, Richards M, et al. Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital. Intern Med J 2006; 36: 37-42.
  • 29. Dunagan WC, Woodward RS, Medoff G, et al. Antibiotic misuse in two clinical situations: positive blood culture and administration of aminoglycosides. Rev Infect Dis 1991; 13: 405-412.
  • 30. Johnson MW, Mitch WE, Heller AH, Spector R. The impact of an educational program on gentamicin use in a teaching hospital. Am J Med 1982; 73: 9-14.
  • 31. Wu WJ, Sha SH, Schacht J. Recent advances in understanding aminoglycoside ototoxicity and its prevention. Audiol Neurootol 2002; 7: 171-174.
  • 32. Chen FQ, Schacht J, Sha SH. Aminoglycoside-induced histone deacetylation and hair cell death in the mouse cochlea. J Neurochem 2009; 108: 1226-1236.
  • 33. Black FO, Gianna-Poulin C, Pesznecker SC. Recovery from vestibular ototoxicity. Otol Neurotol 2001; 22: 662-671.
  • 34. Ahmed RM, MacDougall HG, Halmagyi GM. Unilateral gentamicin vestibulotoxicity. Otol Neurotol 2011; 32: 1158-1162.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.