Can vancomycin cause ototoxicity?

Vancomycin and Ototoxicity

Vancomycin can cause ototoxicity, but this adverse effect is relatively rare with modern formulations and occurs primarily when vancomycin is combined with other ototoxic agents or in patients with specific risk factors. 1

Risk Factors for Vancomycin-Associated Ototoxicity

• Age: Patients older than 53 years appear to be at higher risk (19% incidence vs 0% in younger patients) 2
• Concomitant ototoxic medications: Risk increases significantly when vancomycin is given with other ototoxic agents, particularly aminoglycosides 3
• Excessive serum levels: While the correlation between serum levels and ototoxicity is not as clear as with nephrotoxicity, very high levels may increase risk 1
• Duration of therapy: Prolonged therapy may increase risk, though recent evidence suggests the risk remains low even with extended treatment 4

Clinical Manifestations

Vancomycin-associated ototoxicity may present as:

• Tinnitus (ringing in the ears)
• Vertigo or dizziness
• Sensation of fullness in the ears
• Decreased hearing acuity (often high-frequency hearing loss first)
• Changes in volume perception during conversations 3

Evidence on Prevalence and Risk

The FDA drug label specifically warns that "ototoxicity has occurred in patients receiving vancomycin" and that it "may be transient or permanent." It occurs most commonly in patients who:

• Receive excessive doses
• Have underlying hearing loss
• Are receiving concomitant therapy with another ototoxic agent 1

Recent research indicates:

• A 2019 study found only 8% of patients receiving long-term vancomycin (≥14 days) experienced worsening changes in hearing from baseline, with only 3% developing moderate-to-severe hearing loss 4
• A 2009 study detected a 12% rate of high-frequency hearing loss in patients after an average of 27 days of vancomycin therapy 2

Monitoring Recommendations

According to the Infectious Diseases Society of America guidelines:

1. Routine audiometric monitoring is not generally recommended during vancomycin therapy alone 3
2. Clinical monitoring should be implemented:
   • Patients and caregivers should be instructed to monitor for otologic symptoms
   • Any changes in hearing, development of tinnitus, vertigo, or ear fullness should prompt consideration of audiometric evaluation and/or discontinuation of therapy 3
3. Special populations requiring closer monitoring:
   • Patients receiving concurrent aminoglycosides or other ototoxic agents
   • Elderly patients (>53 years) 2
   • Patients with pre-existing hearing impairment
   • Patients requiring prolonged therapy (>4-6 weeks) 3

Prevention Strategies

1. Avoid concurrent ototoxic medications when possible, particularly aminoglycosides 3
2. Monitor vancomycin levels to avoid excessive serum concentrations
   • While toxicity correlation with serum levels is not as clear as with nephrotoxicity, maintaining appropriate levels is prudent 3
3. Consider alternative agents in high-risk patients when clinically appropriate
4. Adjust dosing in patients with renal dysfunction to prevent accumulation 1

Management of Suspected Ototoxicity

If ototoxicity is suspected:

1. Obtain audiometric evaluation
2. Consider discontinuation of vancomycin if clinically feasible
3. Switch to alternative antimicrobial therapy if necessary
4. Monitor for resolution of symptoms (may be transient or permanent) 1

Unusual Cases

While systemic absorption of oral vancomycin is typically poor, rare cases of ototoxicity have been reported with oral administration, particularly in patients with compromised intestinal epithelium that may allow increased drug absorption 5.

Bottom Line

Vancomycin-associated ototoxicity is a recognized but relatively uncommon adverse effect with modern vancomycin formulations. The benefit of vancomycin therapy typically outweighs this risk for most patients with serious gram-positive infections. Clinical monitoring for symptoms is appropriate for most patients, with audiometric testing reserved for high-risk individuals or those who develop symptoms.