Intravesical gentamicin protocol - Royal Devon & Exeter Hospital
Intravesical gentamicin protocol - Royal Devon & Exeter Hospital Intravesical gentamicin protocol - Royal Devon & Exeter Hospital
Urology DepartmentRoyal Devon and Exeter Hospital,Barrack Road,Exeter, EX2 5DW.01392 402 539 (9am–5pm)Date: ________________Dear ,Re: Intravesical GentamicinName & ID number: ________________________I have arranged for this patient to self administer intravesical gentamicin for their refractory,recurrent urinary tract infections. This treatment has been shown to work in a number ofpatients where continuous oral prophylaxis has been ineffective or is poorly tolerated.The patient will catheterise themselves at night and self administer 80mg of gentamicindiluted in 50mls of sterile sodium chloride 0.9% which will be left in the bladder overnight oruntil they first void. Complications and side effects are very rare with this treatment thoughserum gentamicin levels will be checked after an interval. Please find a copy of the patientinformation sheet enclosed.I have arranged for them to be taught how to self catheterise and have arranged for thepatient to be supplied with vials of gentamicin (80mg/2mls) and 20ml sodium chloride 0.9%ampoules (three per dose) via the Wonford Hospital Pharmacy.Could you supply them with catheters, 50ml syringes and green 21g needles to allow themto draw up and dilute the gentamicin in saline?I will review the patient in four weeks to monitor their progress but in the meantime anyfurther information can be obtained from me via my secretary on 01392 402 539 or from theclinical nurse specialists in Clinical Measurement on 01392 402 136.Yours sincerely,
Intravesical Gentamicin PrescriptionAuthorisation Form (PAF)This form must be completed by a Urology Consultant and sent topharmacy prior to initiation of intravesical gentamicin therapy.PATIENT DETAILSNHS Number of patientPatient namePatient AddressPatient Post CodePatient DOB DD MM YYYYGentamicin injection is an aminoglycoside antibiotic licensed forparenteral use. Intravesical instillation is un-licensed in the UK.Prescribers declaration Yes/No #Conventional measures to reduce the frequency of UTIs has failedY / NPatient is competent to self-catheterise intermittentlyPatient understands that this treatment is of unproven benefit and has not beensubjected to detailed research.Patient consents to this novel therapyThe patient has been provided with verbal and written information about thetreatment including the patient information sheet (appendix 1)The patient’s GP has or will be sent a letter detailing the rationale for treatment,treatment regimen, potential complications, and contact numbers (appendix 2)# All answers must be yes or Pharmacy will not dispense.Y / NY / NY / NY / NY / NSigned:____________________________Date:_________________________________SEND COMPLETED PAF TO THE PHARMACY AT THE ROYAL DEVON AND EXETERHOSPITAL WITH THE INITIAL INTRAVESICAL GENTAMICIN PRESCRIPTION.Pharmacy will file this PAF so that further supplies can be issued against it.
- Page 1 and 2: INTRAVESICAL GENTAMICIN GUIDELINEPo
- Page 3 and 4: 3. TREATMENT PROTOCOL (ADAPTED FROM
- Page 5: Patient information sheetGentamicin
<strong>Intravesical</strong> Gentamicin PrescriptionAuthorisation Form (PAF)This form must be completed by a Urology Consultant and sent topharmacy prior to initiation of intravesical <strong>gentamicin</strong> therapy.PATIENT DETAILSNHS Number of patientPatient namePatient AddressPatient Post CodePatient DOB DD MM YYYYGentamicin injection is an aminoglycoside antibiotic licensed forparenteral use. <strong>Intravesical</strong> instillation is un-licensed in the UK.Prescribers declaration Yes/No #Conventional measures to reduce the frequency of UTIs has failedY / NPatient is competent to self-catheterise intermittentlyPatient understands that this treatment is of unproven benefit and has not beensubjected to detailed research.Patient consents to this novel therapyThe patient has been provided with verbal and written information about thetreatment including the patient information sheet (appendix 1)The patient’s GP has or will be sent a letter detailing the rationale for treatment,treatment regimen, potential complications, and contact numbers (appendix 2)# All answers must be yes or Pharmacy will not dispense.Y / NY / NY / NY / NY / NSigned:____________________________Date:_________________________________SEND COMPLETED PAF TO THE PHARMACY AT THE ROYAL DEVON AND EXETERHOSPITAL WITH THE INITIAL INTRAVESICAL GENTAMICIN PRESCRIPTION.Pharmacy will file this PAF so that further supplies can be issued against it.
Change language