title: Discontinuation of peri-operative gentamicin use for indwelling urinary catheter manipulation in orthopaedic surgery.
abstract: BACKGROUND
  Gentamicin has historically been used prior to insertion and removal of indwelling urinary catheters (IDCs) around elective joint replacement surgery to prevent infection; however, this indication is not recognized in the Australian Therapeutic Guidelines: Antibiotic and the paradigm for safe use of gentamicin has shifted.
  
  
  METHODS
  The antimicrobial stewardship team of a 500 bed tertiary regional hospital performed a retrospective clinical study of gentamicin IDC prophylaxis around total hip and knee arthroplasties. Results were presented to the orthopaedic surgeons. A literature review identified no guidelines to support gentamicin prophylaxis and only a very low risk of bacteraemia associated with IDC insertion/removal in patients with established bacteriuria. Consensus was reached with the surgeons to discontinue this practice. Subsequent prospective data collection was commenced to determine effectiveness, with weekly feedback to the Department Head of Orthopaedics.
  
  
  RESULTS
  Data from 137 operations pre-intervention (6 months) were compared with 205 operations post-intervention (12 months). The median patient age was 72 years in both groups. Following the intervention, reductions in gentamicin use were demonstrated for IDC insertion (59/137 (42%) to 4/205 (2%), P < 0.01) and removal (39/137 (28%) to 6/205 (3%), P < 0.01). No gentamicin use was observed during the final 40 weeks of the post-intervention period. There were no significant differences between the groups for pre-operative bacteriuria, surgical site infections or acute kidney injury.
  
  
  CONCLUSIONS
  A collaborative approach using quality improvement methodology can lead to an evidence-based reappraisal of established practice. Regular rolling audits and timely feedback were useful in sustaining change.
authors.affiliation: Department of Pharmacy, Wollongong Hospital, Wollongong, New South Wales, Australia.|Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.
authors.forename: Stuart E
authors.initials: SE
authors.lastname: Bond
authors.affiliation: Department of Infectious Diseases, Wollongong Hospital, Wollongong, New South Wales, Australia.
authors.forename: Craig S
authors.initials: CS
authors.lastname: Boutlis
authors.affiliation: Department of Orthopaedic Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia.
authors.forename: Stuart G
authors.initials: SG
authors.lastname: Jansen
authors.affiliation: Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.|Department of Infectious Diseases, Wollongong Hospital, Wollongong, New South Wales, Australia.
authors.forename: Spiros
authors.initials: S
authors.lastname: Miyakis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis / Q000592:standards; D001178:Arthroplasty / Q000009:adverse effects*; D001315:Australia / Q000453:epidemiology; D016470:Bacteremia / Q000188:drug therapy / Q000517:prevention & control; D001437:Bacteriuria / Q000188:drug therapy / Q000517:prevention & control; D002408:Catheters, Indwelling / Q000009:adverse effects / Q000382:microbiology / Q000592:standards*; D020878:Device Removal / Q000009:adverse effects / Q000592:standards; D005260:Female; D005839:Gentamicins / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D019637:Orthopedic Procedures / Q000009:adverse effects*; D019990:Perioperative Care / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000517:prevention & control; D062885:Urinary Catheters / Q000382:microbiology*
chemical_list: D000900:Anti-Bacterial Agents; D005839:Gentamicins
keywords: antibiotic prophylaxis; arthroplasty; gentamicin; indwelling catheters; surgical site infection