Intravesical gentamicin has long been proven an effective option in the treatment of recurrent urinary tract infections, especially those caused by multidrug resistant microorganisms (1). It is well tolerated, local administration reduces systemic side effects (2, 3), use can be protocolised and it can be patient administered.  However use remains sporadic and there lacks a consensus regimen for administration. We set out to investigate the usage of this intravesical option and to draw on experts experience to determine whether a universal protocol could be constructed.

A 10 question survey was constructed (Figure 1) and distributed through the platforms of the International Continence Society (ISC) and the Scottish Pelvic Floor Network (SPFN). 40 responses were gained from around the world.

77.5% (n=31) of respondents reported using intravesical gentamicin for the treatment of recurrent urinary tract infections, with 5 of these centres also using it as a prophylaxis during catheter changes. 9 centres reported not using intravesical gentamicin. Of the 31 respondents using this treatment for recurrent urinary tract infections, 74.2% (n=23) report it being administered by the patient themselves, with 25.8% (n=8) utilising a specialist nurse or district nurse for administration only, and some centres offering more than one option. Dosing regimen varied dramatically from a dose of 12mg up to 240mg, and from frequency of twice daily to once weekly (Figure 2). The most commonly used dose was 80mg (51.6%, n=16) in 50ml saline once daily. 90.3% (n=28) used intermittent catheterisation to administer the antibiotic, whilst the remainder used indwelling catheters for administration. 67.7% (n=21) reported no complications at all, whilst 13% (n=4) observed resistance as a complication. Of those centres (n=9) who do not use this treatment, expense was cited as the most common barrier.

Intravesical gentamicin has been shown to be an effective and well accepted treatment option throughout the world with expert experience revealing very few complications. Given that it is well tolerated, it can be patient administered and protocolised it ought to be brought into mainstream practice. Generally, there lacks a blanket policy on its use, however we have now shown that the consensus option within expert hands is the use of 80mg gentamicin in 50mls saline once daily administered via intermittent self catheterisation.

Shifting the paradigm to patient administration empowers patient to become more invested in their treatment, frees up clinician time and, in the face of the current global pandemic, it crucially reduces hospital attendance. Intravesical gentamicin ought to be more widely used, and in bringing together this expert experience from across the globe, we have shown that protocolisation is possible and have highlighted the most commonly used regimen. Moving forwards, we would construct and distribute a protocolised regime, inviting centres to draw upon this consensus opinion by adopting this protocol in order to standardise practice. We would also look to investigate the patients' perspective: to find out what patients find challenging about administration; opening vials, mixing solutions, self catheterising, and to explore ways to improve the patient experience.

Stalenhoef JE, van Nieuwkoop C, Menken PH, Bernards ST, Elzevier HW, van Dissel JT. Intravesical Gentamicin Treatment for Recurrent Urinary Tract Infections Caused by Multidrug Resistant Bacteria. J Urol. 2019 Mar;201(3):549-555. doi: 10.1016/j.juro.2018.10.004. PMID: 30316898.
Abrams P, Hashim H, Tomson C, Macgowan A, Skews R, Warren K. The use of intravesical gentamicin to treat recurrent urinary tract infections in lower urinary tract dysfunction. Neurourol Urodyn. 2017 Nov;36(8):2109-2116. doi: 10.1002/nau.23250. Epub 2017 May 15. PMID: 28503891.
Pietropaolo A, Jones P, Moors M, Birch B, Somani BK. Use and Effectiveness of Antimicrobial Intravesical Treatment for Prophylaxis and Treatment of Recurrent Urinary Tract Infections (UTIs): a Systematic Review. Curr Urol Rep. 2018 Aug 9;19(10):78. doi: 10.1007/s11934-018-0834-8. PMID: 30094687; PMCID: PMC6097067.