Intra-Vesical Gentamicin (IVG) installations improve QoL and reduce micro-organism resistance in patients with recurrent UTIs.

Introductions:
	
Recurrent [r] UTIs can be challenging to manage if there is no structural or functional urological cause identified.  In the case of rUTIs, several prophylactic measurements are taken to prevent these infections from occurring ie; lifestyle modifications, prophylaxis antibiotics, and installation of intra-vesical substances.   Recurrent UTIs have a detrimental effect on patient QoL[1], put them at risk of developing potentially life-threatening urosepsis and increases micro-organism resistance to antibiotics which is a global issue. 
The aims of the study were to assess if using Intra-Vesical Gentamicin (IVG) could improve QoL by reducing pelvic pain, reduce the recurrence of UTIs and assessing the effects on micro-organism resistance. Another aim was to   encourage the patient to  self manage their treatment, reduce hospital visits and reduce  intervention by  primary health care  care team.

Material & Methods:

A treatment protocol was developed and agreed by the local Clinical Effectiveness Committee and 11 patients were identified as suitable for this prospective study.  Inclusion criteria were those who failed all conventional treatments for rUTIs which included

>6 proven UTI,s in  a twelve month period or 
At least one proven  uro sepsis  requiring hospital admission in the previous twelve months
Discussion   with consultant micro biologist  to ensure no other  oral antibiotics were  an option, and that the patients do not have gentamicin resistant organisms.
All conservative treatment exhausted
 i.e Fluid Advice,  voiding diaries,BAUS Information leaflet on Cystitis, constipation and sexual health
Patients have failed on long term antibiotic prophylaxis  including Hipprex
Cystistat or iAluril instillations have failed
Patient able to perform intermittent self catheterisation
Ensure Upper Tract imaging and Cystoscopy have been carried out prior to commencing treatment


All patients were consented to this off-licence use of IVG and given the written protocol.  A single nightly instillation of 80 mg Gentamicin diluted in 50 ml of 0/9% normal saline was instigated.  The patient was instructed in the technique of intermittent self catheterisation. and how to prepare and administer the IVG. Serum Gentamicin levels were checked seven days post-treatment.  If levels were > 1.0 mg/L treatment had to be discontinued (all patient levels were < 1.0 mg/L).  Daily instillations were reduced in frequency over subsequent months dictated by response.
We reviewed all positive urine samples pre & post-IVG and documented causative micro-organisms and their sensitivities and resistance.

Results:

Eleven patients were included (ten females, one male) with an average age of 45 (70-22), average BMI: 23.6 (29-17) and average treatment period: 7 months (2-18).  All patients were independent in administration. Overall 10 out of 11 (91%) had an improvement in their pelvic pain & rate of rUTI. Comparing pre and post IVG results, there was improvement in pain scores 9.8/10 to 5.1/10 and number of symptomatic UTIs reduced from 8.3 to 1.8.  There were fewer admissions for intravenous ABx (mean 1.45 to 0.36) and fewer multidrug resistance organisms after IVG (mean 7.38 vs. 1). 
Antibiotic	Pre-IVG resistance %	Post-IVG resistance %
Amoxicillin	       67%     	                               35%
Co-Amoxiclav	36%	                                     15%
Trimethoprim	60.8%	                              25%
Nitrofurantoin	3.1%	                               0%
Cefalexin	      21.6%	                                10%
Ciprofloxacin	      23.7%	                                 15%
Gentamicin	       3.1%	                                          0%

Reviewing the table above, IVG has reduced micro-organism resistance to the majority of Abx used in UTIs.

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Conclusion: 
We have concluded that IVG reduces the frequency of UTIs. It  can be administered safely and reduces micro-organism resistance or at least not increasing it.  Patients have also reported improved quality of life with the reduction in Symptoms of urinary tract Infection which included, frequency of micturition and nocturia. We intend to recruit more suitable patients and continue follow up to assess IVG effectiveness in the longer term.

Recurrent Lower Urinary Tract Infections Have a Detrimental Effect on Patient Quality of Life: a Prospective, Observational Study.