What antibiotics cause tinnitus and hearing loss?

October 6, 2025 •

5 min read

According to a 2023 review, aminoglycoside antibiotics carry a risk of ototoxicity leading to tinnitus and hearing loss. While these are powerful, life-saving medications, it is crucial to understand what antibiotics cause tinnitus and hearing loss and the potential consequences of their use.

Quick Summary

Certain antibiotics, notably the aminoglycosides and, less commonly, some macrolides and vancomycin, can cause inner ear damage (ototoxicity). This can result in symptoms like tinnitus, hearing loss, and balance issues.

Key Points

Aminoglycosides pose the highest risk of ototoxicity: Antibiotics like gentamicin, amikacin, and streptomycin are the most common culprits for causing permanent inner ear damage, including hearing loss and vestibular issues.
Vancomycin carries a risk, especially with high doses: While less common with modern preparations, vancomycin can cause ototoxicity, particularly when used in high doses, for prolonged periods, or in patients with kidney problems.
Macrolides are associated with temporary tinnitus and hearing loss: Azithromycin and clarithromycin have been linked to reversible hearing loss and tinnitus, particularly with high or prolonged dosing.
Symptoms include tinnitus and balance issues: Early signs often include a ringing or buzzing in the ears (tinnitus) and unsteadiness, which can precede noticeable hearing loss.
Genetic predisposition is a major risk factor: Certain mitochondrial gene mutations can significantly increase an individual's susceptibility to aminoglycoside ototoxicity, even at recommended doses.
Damage is often irreversible: Because the inner ear hair cells destroyed by ototoxic drugs do not regenerate, the hearing loss is often permanent, particularly with aminoglycosides.
Risk can be mitigated through careful monitoring: Minimizing dose, duration, and co-administration of other ototoxic drugs, along with baseline hearing tests and monitoring blood levels, can help reduce the risk.

Understanding antibiotic-induced ototoxicity

Ototoxicity is the potential for a substance to damage the inner ear, leading to hearing loss, tinnitus, and balance problems. While many classes of drugs can cause ototoxicity, certain antibiotics are among the most notorious culprits. This is because some antibiotics can damage the delicate sensory hair cells in the cochlea, the snail-shaped part of the inner ear responsible for converting sound vibrations into nerve signals. Since these hair cells do not regenerate in humans, the damage is often permanent.

The primary culprits: Aminoglycoside antibiotics

The class of antibiotics most frequently associated with irreversible ototoxicity is the aminoglycosides. These powerful antibiotics are reserved for treating severe bacterial infections, such as sepsis, meningitis, and infections resistant to other drugs. They are highly effective at combating bacteria but carry a significant risk of damaging both the auditory (cochleotoxic) and balance (vestibulotoxic) systems of the inner ear.

Some common aminoglycoside antibiotics known for their ototoxic potential include:

Gentamicin: One of the most frequently used aminoglycosides, gentamicin is often administered intravenously for severe infections and is particularly known for causing vestibular (balance) issues, though it can also be cochleotoxic.
Tobramycin: Another common aminoglycoside, tobramycin can cause both auditory and vestibular toxicity. It is often used to treat infections in cystic fibrosis patients, who may receive repeated, long-term courses, increasing their cumulative risk.
Neomycin: Considered one of the most highly toxic aminoglycosides, neomycin is generally reserved for topical or oral use due to its high risk of cochlear damage.
Amikacin: While often considered less toxic than some other aminoglycosides, amikacin can still cause permanent hearing loss, especially with high cumulative doses.
Streptomycin: Historically used to treat tuberculosis, streptomycin is known for causing both hearing and balance problems.

Damage from aminoglycosides often begins at the high frequencies of hearing, which is why audiometric monitoring is recommended for high-risk patients. Because these drugs are critical for treating life-threatening conditions, the clinical decision to use them is a careful balancing act between saving a patient's life and managing the risk of long-term side effects.

Other antibiotics with ototoxic potential

While aminoglycosides are the most prominent, other antibiotics have also been linked to ototoxic effects, though typically at a lower frequency or severity.

Vancomycin

Vancomycin is a glycopeptide antibiotic used for severe Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA). Early reports of vancomycin ototoxicity may have been influenced by impurities in older formulations or by concomitant use with other ototoxic drugs, particularly aminoglycosides. However, modern studies still acknowledge its ototoxic potential, especially with high doses, prolonged treatment, and reduced kidney function. Hearing loss associated with vancomycin is rare, but case reports of reversible and irreversible damage exist, emphasizing the need for monitoring in high-risk scenarios.

Macrolide antibiotics

Macrolides, such as azithromycin and clarithromycin, are widely prescribed for common respiratory tract and skin infections. While the evidence is less conclusive than for aminoglycosides, multiple studies and case reports have found associations between macrolide use and transient or permanent hearing loss and tinnitus. These effects are most often linked to high doses, long-term therapy, pre-existing hearing loss, or kidney/liver dysfunction. One large meta-analysis found a statistically significant increased risk of hearing loss with macrolide use compared to controls, suggesting a need for careful consideration during prescribing.

Signs and symptoms of antibiotic-induced ototoxicity

Being aware of the potential symptoms of ototoxicity is crucial for early detection and intervention. The signs can be subtle and may appear during treatment or even weeks after the medication has been discontinued.

Common signs and symptoms include:

Tinnitus: A ringing, buzzing, or hissing sound in one or both ears. Tinnitus often precedes or accompanies hearing loss and is one of the most common early indicators.
Hearing loss: Difficulty hearing, particularly with high-pitched sounds like women's or children's voices. In severe cases, profound deafness can occur.
Dizziness and vertigo: A feeling of unsteadiness, spinning, or loss of balance. This is especially prevalent with vestibular-toxic agents like gentamicin.
Oscillopsia: A visual disturbance in which objects appear to bounce or jump around when the head is moving. This is a symptom of bilateral vestibular damage.
Fullness or pressure: A sensation of pressure in the ear, similar to during a change in altitude.

Comparison of ototoxic antibiotic classes


Feature	Aminoglycosides	Vancomycin	Macrolides (e.g., Azithromycin)
Toxicity Risk	High; often permanent	Low to moderate; risk increases with dose and kidney issues	Low to moderate; mainly with high/prolonged doses
Damage Type	Irreversible sensorineural hearing loss and vestibular damage due to hair cell death	Mostly reversible sensorineural hearing loss, often temporary, but irreversible cases reported	Often transient sensorineural hearing loss and tinnitus, but can be permanent
Key Examples	Gentamicin, Tobramycin, Amikacin, Neomycin	Vancomycin	Azithromycin, Clarithromycin
Clinical Context	Reserved for severe, life-threatening bacterial infections	Severe Gram-positive infections, including MRSA	Common respiratory and skin infections; often outpatient use
Risk Factors	High cumulative dose, impaired renal function, genetic predisposition	High doses, renal dysfunction, concurrent ototoxic medications	High doses, prolonged use, elderly, kidney/liver disease

How to mitigate the risks of antibiotic-induced hearing damage

While some ototoxic medications are unavoidable in certain critical situations, healthcare providers and patients can take several steps to minimize risk:

Clinical Monitoring: For high-risk patients, baseline and periodic hearing tests (audiograms) should be performed to detect changes early. Drug levels and renal function should also be closely monitored, as drug accumulation can increase toxicity.
Minimize Exposure: Using the lowest effective dose for the shortest possible duration reduces the overall cumulative exposure and risk of damage.
Avoid Concurrent Ototoxins: Whenever possible, avoid prescribing multiple ototoxic medications (e.g., aminoglycosides with loop diuretics or vancomycin), as the combination can increase the risk of damage.
Awareness of Symptoms: Patients and caregivers should be educated on the signs of ototoxicity, such as new or worsening tinnitus, so they can report them promptly to their doctor. Discontinuing the drug at the earliest sign of toxicity may prevent further damage.
Explore Alternatives: In non-emergency situations, using non-ototoxic alternatives may be a safer choice, especially for patients with other risk factors or pre-existing hearing loss.
Genetic Testing: For patients with a family history of hearing loss, genetic testing for mutations like m.1555A>G in mitochondrial DNA can identify those at significantly increased risk of developing ototoxicity from aminoglycosides.

Conclusion

For most people, antibiotics are a safe and effective treatment for bacterial infections. However, awareness is key when considering powerful, potentially ototoxic drugs like aminoglycosides, vancomycin, and macrolides. While the risk of hearing loss and tinnitus from some antibiotics is low, the consequences can be permanent and severe, especially with high-dose, long-term, or intravenous use, or in the presence of other risk factors. By understanding the specific antibiotics involved, recognizing the symptoms, and working closely with a healthcare provider, patients can ensure the safest possible treatment while protecting their hearing health. The decision to use these medications is always weighed against the benefit of treating potentially life-threatening infections, but vigilance and monitoring are critical components of care.

For more detailed information on ototoxic medications, refer to the authoritative article on Frontiers in Cellular Neuroscience: Towards the Prevention of Aminoglycoside-Related Hearing Loss.

Frequently Asked Questions

The class of antibiotics known as aminoglycosides poses the highest risk for causing hearing loss. Specific examples include gentamicin, amikacin, streptomycin, neomycin, and tobramycin.

Yes. Aminoglycoside antibiotics can cause permanent hearing loss by destroying the delicate hair cells of the inner ear. Since these cells do not regenerate, the damage is often irreversible.

One of the most common first signs is tinnitus, a sensation of ringing, buzzing, or hissing in the ears. This can be accompanied by a feeling of fullness in the ear or difficulty with balance.

Vancomycin has been linked to ototoxicity, though the risk is considered low with modern formulations. The risk increases with high doses, prolonged therapy, impaired kidney function, and the concurrent use of other ototoxic drugs like aminoglycosides.

Macrolide antibiotics like azithromycin have been associated with reports of tinnitus and hearing loss, though the effects are often transient. The risk is typically linked to high-dose or long-term use and often resolves after the drug is stopped.

While some drug-induced hearing issues can be temporary and reversible, the damage caused by potent ototoxic antibiotics like aminoglycosides is often permanent. Early detection and discontinuation of the drug may prevent further damage.

Several factors increase the risk, including having a high cumulative dose, prolonged treatment duration, pre-existing kidney disease, concurrent use of other ototoxic medications (like certain diuretics), older age, and having a genetic predisposition.

Doctors minimize risk by using the lowest effective dose for the shortest duration, monitoring drug levels in the blood, and performing baseline and follow-up hearing tests for high-risk patients. They may also avoid prescribing other ototoxic drugs concurrently.

Children can be at risk, particularly in intensive care settings where powerful antibiotics like aminoglycosides are used. The inner ears of young children are especially sensitive during key developmental periods.