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Local instillation of aminoglycosides for a variety of indications is gaining more widespread use in a selected set of clinical situations where aminoglycoside levels can be concentrated at specific tissue sites. The use of aminoglycoside-loaded beads for the prevention and treatment of bone and joint infections have become commonplace as a strategy to limit nephrotoxicity, while providing antimicrobial activity of aminoglycosides at the tissue level.323 Local concentrations of aminoglycoside are achieved for prolonged periods when administered by this route. Aminoglycoside aerosol delivery systems are now in use to provide high intrapulmonary antibiotic levels with minimal systemic and kidney concentrations of the antibiotic. This strategy has been used successfully in cystic fibrosis patients for the management of difficult-to-treat Gram-negative bacillary pneumonia.324,325 However, significant nephrotoxicity with the use of inhaled tobramycin has been described in at least two cases.326,327
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