Can vancomycin and cefepime (Cefepime) cause ototoxicity?

Can Vancomycin and Cefepime Cause Ototoxicity?

Yes, vancomycin can cause ototoxicity, though it is rare with modern formulations, while cefepime is not recognized as an ototoxic agent in clinical practice.

Vancomycin and Ototoxicity

Vancomycin has documented ototoxic potential, though the actual risk remains relatively low with contemporary purified formulations and appropriate dosing:

Evidence of Ototoxicity

• Historical context: Most reports of vancomycin ototoxicity were associated with early, impure formulations used over 30 years ago, with 28 published cases since 1958 1

• Modern data shows low but measurable risk: In patients receiving long-term IV vancomycin (median 30 days), 8% experienced worsening hearing changes, with 3% developing moderate-to-severe hearing loss 2

• Age is a critical risk factor: Patients over 53 years old had a 19% incidence of high-frequency hearing loss on audiometry after an average of 27 days of therapy, while patients under 53 years had 0% incidence 3

Clinical Characteristics

• Presentation: Ototoxicity typically manifests as high-frequency hearing loss, tinnitus, and rarely vestibular symptoms 4

• Reversibility unclear: It remains uncertain whether vancomycin-induced hearing impairment is permanent or reversible, as few patients had follow-up audiometry 1

• Onset timing: Symptoms can occur even with short-term therapy, as demonstrated by a case where ototoxicity developed after just three doses of oral vancomycin 5

Risk Factors and Monitoring

Key risk factors include:

• Advanced age (>53 years) 3
• Prolonged therapy duration 4
• Concomitant use of other ototoxic agents, particularly aminoglycosides 1
• High serum trough levels, though the exact correlation remains unclear 3

Monitoring recommendations from guidelines:

• Vancomycin should be infused over ≥1 hour to reduce adverse reactions 4
• Target trough levels of 10-15 μg/mL for most indications 4
• While routine audiometry is not standard, it should be considered in high-risk patients (elderly, prolonged therapy, concomitant ototoxic drugs) 2

Important Caveat

Vancomycin is rarely ototoxic as monotherapy 4. The American Heart Association guidelines note that prolonged IV vancomycin use "may be complicated by thrombophlebitis, rash, fever, anemia, thrombocytopenia, and, rarely, ototoxic reactions" 4, emphasizing the rarity of this complication.

Cefepime and Ototoxicity

Cefepime is NOT associated with ototoxicity in clinical practice or medical literature:

• Multiple guidelines recommend cefepime in combination regimens for serious infections, including endocarditis, without any mention of ototoxicity risk 4

• The American Heart Association guidelines specifically list cefepime for prosthetic valve endocarditis without ototoxicity warnings 4

• Cephalosporins as a class are not recognized as ototoxic agents, though they may increase nephrotoxicity risk when combined with aminoglycosides 4

Clinical Implications

When using vancomycin:

• Exercise particular caution in patients >53 years receiving prolonged therapy 3
• Avoid concomitant aminoglycosides when possible to minimize cumulative ototoxic risk 1
• Counsel patients about potential auditory symptoms (tinnitus, hearing loss, "buzzing") 5
• Consider baseline and follow-up audiometry in high-risk patients, though routine monitoring remains controversial 2

When using cefepime:

• No special precautions for ototoxicity are needed
• Can be safely combined with vancomycin without additive ototoxic risk 4