Recurrent UTIs are challenging, and their persistence and relapse after treatment warrant a different
management approach. Systemic antibiotics remain to be the primary treatment for UTI. However, with increasing
antimicrobial resistance and growing evidence of microbiota dysbiosis with systemic therapy, there
is a growing need for targeted antibiotic therapies[1]. Intravesical antibiotic therapy is known to provide high drug concentrations locally and minimise their systemic side effects[2,3]. Our aim was to assess the efficacy of intravesical Gentamicin among our patients with refractory UTIs.

In April 2021, we established a multidisciplinary complex UTI clinic in collaboration with specialist nurses and microbiologists. A prospective study was done between May 2021- May 2023 including the patients referred to our complex UTI clinic, who in view of refractory symptoms to 1st and 2nd line treatments, subsequently received Intravesical Gentamicin.  These patients had repeat culture sensitivities checked after which cases were discussed at our UTI MDT meeting. If initiation of intravesical Gentamicin is considered, the patients received the therapy through a locally devised Nurse-led protocol (Figure 1)and response was assessed at follow up clinic appointments.

41 patients were included [(Male: 10, Female:31, Mean age: 54+/-16.78)]. 40 (98%) patients had significant comorbidities including 11 (27%) who were immunocompromised and 49% with underlying neuropathy. 19 (46%) patients had E. coli isolated from urine
cultures however, 44% had multidrug resistance pattern with UTI frequency of &gt;6 episodes/ year in over 70% patients. Mean follow up was 15 months. Post Gentamicin Instillations, undetectable  serum Gentamicin levels were found in 100% patients. On Gentamicin administration, Hospital admission rates due to urosepsis reduced from 41% to 5 % (p-value= 0.005). Presence of multi-drug resistance on the urine cultures reduced from 44% to 10% (p-value= 0.005). 76% patients showed significant reduction in the frequency of UTIs (p-value <0.001). 71% patients reported good to excellent PGI-I (Patient Global Impression of Improvement) score (p-value <0.001). Improvement in Quality of Life from poor to good or excellent was seen in 76% patients (p-value <0.001).

Intravesical Gentamicin has shown to improve antibiotic sensitivity pattern providing better long term antibiotic options. It also helps in reducing the risks of urosepsis and hospital admissions due to multi-drug resistant bacteria.

Intravesical Gentamicin therapy has shown to reduce the frequency and severity of recurrent UTIs. It is safe and has shown promising benefit for difficult-to-treat UTI as a tertiary treatment option. Multi-Disciplinary Treatment approach (involving the microbiologists) adds a different perspective and dimension to management. Hence, it is advisable to take the decision to administer intravesical gentamicin therapy in a multidisciplinary setting with a microbiologist present. Setting expectations is vital, specially among those with irreversible risk factors like neuropathy)

Morris, C.J.; Rohn, J.L.; Glickman, S.; Mansfield, K.J. Effective Treatments of UTI—Is Intravesical Therapy the Future? Pathogens 2023, 12, 417.
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.
Reddy M, Zimmern PE. Efficacy of antimicrobial intravesical treatment for uncomplicated recurrent urinary tract infections: a systematic review. Int Urogynecol J. 2022 May;33(5):1125-1143