Improving Gentamicin Prescribing and monitoring at HDFT

Introduction

Gentamicin is an antibiotic widely used within the General Surgery department at HDFT and globally It is an highly effective antibiotic that is often used in combination with amoxicillin and metronidazole for broad spectrum cover, due to its excellent gram negative action Due to its narrow therapeutic index it has potentially serious side-effects including nephrotoxicity and ototoxicity As such it is vital to prescribe and monitor Gentamicin correctly

Methods

All in-patients under the General Surgery team receiving Gentamicin were included in this audit

Study periods:

• 01/04/2022 – 27/04/2022 (first cycle)

• 01/05/2022 – 27/05/2022 (second cycle)

Data for 26 patients were collected for the first cycle, and 18 patients for the second cycle. Patients on the paediatric ward were excluded Data was collected using Handover lists, ePMA , WebV, and ICE systems.

Measured 8 criteria, based off the ‘Extended interval Gentamicin Protocol at HDFT’ guidelines We would aim for 100% compliance in each of these categories

Henry Hill

Aim

As an FY2 in the department we noticed shortcomings of serum level monitoring for patients in the department, with many being missed or timings not communicated We sought to assess the compliance in each of the 8 parameters of the Extended interval Gentamicin Protocol within the General Surgical department at HDFT. These are shown in bold withing the trust policy below.

Extended Interval Gentamicin Protocol

Gentamicin prescribing and monitoring is done according to ‘Extended interval Gentamicin Protocol at HDFT’ The main points of this guideline include:

1. Indication for therapy should be documented and correct

2. Gentamicin should not be prescribed if CrCl<30mL/min

3. Initial dosing is done using patient’s IBW, measured using gender and height, or patient actual weight documented

4. Serum gentamicin measurement should be taken 6-14 hours post first-dose. This level is used to determine dosing interval and when repeat levels are required

5. Urea and electrolyte blood tests to be taken daily

6. Gentamicin should be used for a maximum of 5 days

Results & Interventions

The first round of analysis suggested significant shortcomings in the quality of prescription and monitoring. Only 50% of levels were taken in the correct timeframe. We implemented an education session following the first round and added a section of the handover to write level timings.

Despite an improvement in timely attainment of 1st serum levels, which was our initial reasoning for the audit, overall no significant improvement was noted between the two cycles. We believe this may in part have been due to a new rotation of Doctors. It also highlighted the need for further interventions or education

Recommendations & Follow up

• Place posters in Surgical doctor’s office and around Doctor’s mess to further promote adherence to guidelines. (Completed June 2022)

• Aim to implement protocol onto ePMA to include mandatory input of height/weight and indication, prompts for gentamicin level, and prevention of administering further treatment without serum level. (Completed August 2022) Ensure functionality to mandate eGFR from blood results is put into the prescribing information.

• 3rd Audit cycle is scheduled to be undertaken this April/may to correlate the EMPA change with performance with the department from 2022.