High systemic gentamicin levels and ototoxicity after implantation of gentamicin beads in a 70-year-old man—a case report

作者: Paul A G de Klaver , Jan de Koning , Rob P A Janssen , Luc J J Derijks

DOI: 10.3109/17453670903487032

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摘要: Gentamicin beads are used for musculoskeletal infections. is released gradually from the beads, and high gentamicin concentrations achieved only locally. Side effects of rarely to be expected with since low amounts resulting in extremely serum antibiotic (Septopal SPC, Wahlig et al. 1978, Walenkamp 1986). Only one case prolonged raised levels has been described date, but no adverse were reported that (Walenkamp Vree 1981). We present another ototoxicity also. Case A 70-year-old man had a total knee replacement performed because osteoarthritis. He history atrial fibrillation, heart failure, mitral regurgitation, chronic obstructive pulmonary disease, diabetes mellitus, he known drug allergies. never complained hearing loss. The postoperative course was complicated by paralytic ileus, perforation small bowel, acute renal failure (which resolved continous veno-venous hemofiltration) which intensive care necessary day 7 18 postoperatively. The patient re-admitted unit 21 23, bleeding complications. Hearing loss, reversed after few days, on 11 days 400-mg single preoperative intravenous dose gentamicin. admitted again—from 64 67—for caused fluid depletion, filling. On 112, respiratory insufficiency surgery partial bowel resection. During this stay care, fascia dehiscence laparotomy multiple enterocutaneous fistulas performed. A Staphylococcus aureus sepsis 157, purulent arthritis left hip diagnosed 161, treated arthrotomy drainage irrigation implantation 120 162. Girdlestone arthroplasty 176 changed. At time thereafter, normal function (estimated MDRD 65 mL/min/1.73 m2, reference value > 60 m2). Medications during 94-day period included furosemide (20 mg i.v. twice daily initially, later increased 500 every 24 hours), ceftazidim (1,000 3 times daily), flucloxacillin (continuously, 12 g ciprofloxacin (400 potassium chloride (i.v. per os), metoclopramide (10 buprenorphine (70 mcg/h transdermal patch days), midazolam (i.v.), dalteparin (7,500 IE subcutaneously fentanyl olanzapine (5 os, initially reduced once acenocoumarol (per norepinephrine gabapentin (300 daily) spironolactone (25 os daily). 10 (day 172), about sudden severe loss level 0.7 mg/L. trough infusion < 0.5 followed were: 0.9 mg/L 179), 181), 1.0 187), 194), 0.4 201). detectable 4 weeks, above weeks (Figure). period, not through any other route. died 216. No obduction performed. Systemic creatinine concentrations. Total 1. 162, implanted. They changed 176. Discussion Pharmacokinetics Gentamicin-polymethylmethacrylate (gentamicin-PMMA) balls bone cement release locally at concentrations, constant up 80 days. Systemically, detectable: generally, remain below 0.1 In clinical practice, lower can regarded as immeasurable. blood-bone barrier, gives difficulty achieving therapeutic systemic administration, prevents local therapy Renal clearance mainly depends glomerular filtration, amount tubular reabsorption (Chiu 1976). Studies have published pharmacokinetics relatively number patients. Gentamicin measured 5 patients 48–360 measurable 1 (with 360 implanted). After peak 1.8 1, plateau reached. This plasma 73 µmol/L (reference 60–110 µmol/L). excretion depended vascularization surrounding tissues: faster when placed muscle tissue than they sclerotic largest study involved 41 patients. traces found, even numbers (80–180) (Wahlig 1978). report decribes 150 mL/min mL/min). decreased 2 duration beads. In our case, more then weeks. unique; there reports magnitude such long alone. Moreover, indication levels, implanted cases above. cause altered may an uptake blood flow site wound, or possibly impaired barrier.

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