RESUMO
Gentamicin is an aminoglycoside that is widely used in neonatology in spite of its known nephrotoxicity and ototoxicity. Because there are only few cases reported in the literature experience with gentamicin overdosage is limited. We report the case of a preterm (gestational age 32+2 weeks) infant with an accidental administration of a ten-fold dose of gentamicin. The baby was treated with a slight increase of fluid intake and monitoring of renal function and gentamicin levels, respectively. A rapid decrease of the gentamicin level (peak level 44.5 mg/L, extrapolated peak level 65 mg/L) was observed. Nephrotoxicity or ototoxicity did not occur. Because of the small number of described cases, a general recommendation for the management of gentamicin intoxication is not possible. The intensity of treatment depends on renal function and gentamicin level. Only isolated patients will need dialysis or exchange transfusion. The case also demonstrates the need for the continuous discussion about hospital-associated damage and error management systems.
