The patient was a 55-year-old white man, a previous smoker, with a history of hypertension (ongoing medication enalapril 10 mg), pituitary adenoma, and tinnitus, but no hearing loss. He presented a complicated history of a PJI that began after a total left shoulder arthroplasty in October 2019 due to osteoarthritis as follows. The first reoperation was performed 2 months after primary surgery, due to subscapular tendon rupture. Debridement, irrigation, and exchange of modular components was performed. Cultures showed growth of C. acnes in 2/5 intraoperative tissue samples, susceptible to benzylpenicillin and clindamycin, and treatment with oral amoxicillin 1 g t.i.d. for 3 months was initiated. Due to persisting shoulder pain and impaired mobility, the patient was subjected to a two-stage revision surgery 7 months after the second operation. In first session of the two-stage procedure, the prosthetic devices were removed, and a spacer coated with gentamicin-containing bone-cement, bone cement containing both gentamicin and clindamycin, and a gentamicin-impregnated collagen sponge were all applied. Intraoperative cultures still showed growth of C. acnes with the same antibiotic susceptibility pattern in 4/7 samples, and the patient was prescribed oral clindamycin 300 mg t.i.d. for 3 months. After an antibiotic-free interval of four weeks, implantation of a reverse total shoulder prosthesis in the second session of the two-stage procedure was performed in October 2020. During this surgery bone fixation cement containing both gentamicin and vancomycin was used. However, intraoperative cultures again displayed growth of C. acnes, in 1/6 samples, and another 3-month oral course of amoxicillin was initiated. Due to an untenable pain situation, a fifth operation according to the DAIR (Debridement, Antibiotics, and Implant Retention) procedure was performed in September 2021. This time, intraoperative cultures displayed growth of both C. acnes (1/6 samples) and two strains of S. epidermidis (both 2/6). Neither of the S. epidermidis strains was susceptible to ciprofloxacin or clindamycin, but both strains, as well as the C. acnes, were susceptible to vancomycin. To enable outpatient treatment, intravenous dalbavancin (1000 mg initial dose followed by three weekly doses of 500 mg) was started. No therapeutic drug monitoring was performed since this was not available. At a follow-up visit four weeks later, after four doses of dalvavancin at a cumulative dose of 2500 mg, the patient reported that since the first dose of dalbavancin he had noticed a gradual decrease in his hearing ability. He denied former hearing problems, but this could not be objectively verified due to lack of previously performed audiometry. Audiometry showed bilateral sensorineural hearing loss with an air-conducted pure tone average (PTA) of 49 dB in the right ear and 41 dB in the left ear. PTA was calculated as the average for the frequencies 0.5, 1, 2, and 4 kHz. According to classification by The World Health Organization (WHO) in 2008 for hearing impairment, a PTA4 < 20 dB is regarded as normal hearing, PTA4 20 < 35 dB as mild hearing loss and PTA4 35 < 49 dB as moderate hearing loss, at an eight-point scale []. In the higher frequency spectrum high-pitch voices and consonants such as “t”, “h”, “s”, and “f” will be found, which can be difficult to discriminate for individuals with reduced treble hearing. Dalbavancin was immediately discontinued, and the patient’s concomitant medications (amlodipine, testosterone, bromocriptine, and oxycodone) were reviewed for interactions and ototoxic potential, none of which were noted (Electronic medicines compendium in Sweden (). Another 2 months of antibiotics (amoxicillin 1 g t.i.d.) was prescribed for the PJI. Follow-up audiograms showed unresolved hearing loss, with an air-conducted PTA of 41 dB in the right ear and 30 dB in the left ear, and the patient was prescribed hearing aids. Two months after the discontinuation of antibiotics, the patient’s shoulder pain had diminished relative to the pain situation before the fifth operation.