Abstract: PUB029
Tobramycin Nephrotoxicity after Intra-articular Instillation
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Bailoor, Kunal, University of Michigan, Ann Arbor, Michigan, United States
- Bhat, Zeenat Yousuf, University of Michigan, Ann Arbor, Michigan, United States
Introduction
Tobramycin powder is often instilled intra-articularly during operative management of septic arthritis with purportedly reduced risk of toxicity relative to systemic therapy. We present a case of tobramycin nephrotoxicity resulting in AKI requiring hemodialysis.
Case Description
A 70-year-old man who had a history of CKD3 with a baseline serum creatinine of 1.2 as well as osteoarthritis with history of right prosthetic knee replacement was hospitalized for lower extremity cellulitis. He had a complex medical history, most notable for prior bilateral lung transplant in 10/2011 for end stage COPD, atrial fibrillation, and type 2 diabetes mellitus.
He initially presented with severe right lower leg pain and swelling; he was noted to have a new DVT. He was started on anticoagulation and IV cefepime. On evaluation, he was noted to have significant right knee effusion; joint aspiration reveled WBC count of 81,000 and synovial fluid culture growing Citrobacter koseri. He was taken to the OR and after joint washout, had 4 grams of vancomycin powder and 3 bottles of tobramycin powder (approximately 3.6 grams) instilled into the joint. There was no significant blood loss or intra-operative hypotension. His pre-operative serum creatinine was 1.2; approximately 12 hours after returning from the OR, his SCr had risen to 1.63 with hyperkalemia to 6.1. Despite attempts at medical management, the patient became rapidly oliguric with persistent hyperkalemia requiring initiation of hemodialysis. Serum tobramycin levels checked 48 hours after the patient returned from the OR were notable for a serum tobramycin level of 36.8 micrograms per milliliter, and a serum vancomycin level of 19.5 micrograms per milliliter. The patient received daily hemodialysis treatments until serum tobramycin levels dropped to below 1 microgram per milliliter. He had renal recovery and was able to stop hemodialysis approximately one month after his operation.
Discussion
Intra-articular antibiotic administration is often felt to be a safer alternative to systemic therapy with reduced risk of systemic toxicity; however, e present a case were there was significant systemic absorption of an intra-articular aminoglycoside resulting in nephrotoxicity. Aminoglycoside toxicity from intra-articular administration should be considered on the differential diagnosis of post-operative AKI for patients with septic arthritis who undergo this procedure.