Tobramycin bladder instillation

What is tobramycin?

Tobramycin is an antibiotic that works to stop the growth of bacteria. It is a clear liquid medication that comes in a vial. 

Why is tobramycin instilled in the bladder?

Tobramycin is delivered directly (instilled) into the bladder to treat or help prevent urinary tract infections (UTIs), especially when the UTIs are recurrent (repeatedly come back) and the bacteria shows increased resistance to other antibiotics. Your child’s health-care team will decide if this treatment is right for them.

How does tobramycin instillation work?

Tobramycin is mixed with a salt-water solution called normal saline (0.9% saline) before it can be instilled into the bladder through a catheter. The medication sits in the bladder for a period of time so it can work directly at the site of the infection.

Supplies for instillation 

• Tobramycin vial
  
• Sticker label
  
• Luer lock syringe (1 mL or 3 mL)
  
• Blunt filter tip needle
  
• Sharps container
  
• 50 mL catheter tip syringe
  
• Medical grade normal saline
  
• Sterile container 
  
• Alcohol wipes 
  
• Clean towel 
  
• Catheter cap 
  
• Catheter drainage bag (optional)
  
• Supplies needed to insert an intermittent (male anatomy/female anatomy) or indwelling urinary catheter 
  

Can I make my own normal saline solution at home for bladder irrigations and instillations? 

• It is recommended that you use medical grade 0.9% normal saline for the purpose of bladder irrigations and instillations. 
  
• Home-made solution may be an option for select patients. You may discuss this further with your child’s health-care team.
  

Aseptic non-touch technique (ANTT)

The aseptic non-touch technique (ANTT) is used for tobramycin bladder instillation. This technique will help to prevent introducing germs, which may cause or worsen an infection in the bladder. 

To prevent germs from entering your child’s bladder, key parts and key sites need to be cleaned properly and not touched. Key parts include the tips of syringes, needles, and the end of the catheter drainage bag. Key sites include the end of the urinary catheter where the urine exists the bladder. It is important to keep these areas and the overall work environment clean. Use wipeable surfaces to place instillation supplies and scrub all needle, syringe, vial and catheter tips with an alcohol wipe for 15 seconds (“scrub the hub”). Let them dry for 15 seconds before use. It is strongly recommended to have two caregivers present to maintain ANTT during bladder installation.

Steps for performing tobramycin instillation 

You need to empty your child’s bladder of urine and irrigate the bladder with normal saline prior to tobramycin instillation. See Bladder irrigation with normal saline for more information. 

Part 1: Preparing the tobramycin mixture

1. Wash your hands and gather the supplies you will need on a clean work surface.
   
2. Measure out the required amount of 0.9% normal saline that you will mix with tobramycin into the sterile container.   
   
3. Attach the blunt filter tip needle to the luer lock syringe. Avoid touching the tip of the syringe or needle.  
   
4. Remove the outer cap of the tobramycin vial. Scrub the rubber top of the tobramycin vial with an alcohol wipe for 15 seconds, then let dry for 15 seconds.  
   
5. Remove the needle cap. Insert the needle into the tobramycin vial and draw up the required amount of tobramycin prescribed. Remove any air from the syringe by tapping the side of the syringe with your finger and gently pushing the air bubbles back into the vial with the plunger.  
   
6. Press the plunger to add the concentrated tobramycin solution to the normal saline in the sterile container. Discard the syringe and needle into a sharps container.
   
7. Draw up the tobramycin and saline mixture into the catheter tip syringe. Remove any air in the syringe, put the syringe cap on, and place it aside. Label the syringe with a sticker label to help you identify the tobramycin mixture. 

Part 2: Instilling the tobramycin and saline mixture

1. Wipe the end of the catheter with an alcohol wipe for 15 seconds, then let dry for 15 seconds.
   
2. Remove the cap from the tobramycin/saline syringe. Connect the syringe to the end of the catheter and gently push the mixture through the catheter.  
   
3. To keep the tobramycin in the bladder, your child's health-care team may instruct you to remove the catheter from the bladder or keep the catheter inside your child’s bladder with a cap or plug covering the opening of the catheter.
   
4. The tobramycin mixture needs to stay inside your child’s bladder for 1-2 hours, depending on what they were prescribed.

Part 3: Removing the tobramycin 

1. After the required amount of time has passed, drain the tobramycin mixture from your child’s bladder. 
   
   1. If you removed the catheter, insert a new catheter into your child's bladder to drain the mixture.
      
   2. If you left the catheter inside your child’s bladder and capped it, pinch the end of the catheter and remove the cap. You can either:
      
      • empty the tobramycin mixture over a urine hat, toilet or into a diaper until the output stops dripping. Then, remove the catheter; OR
        
      • reconnect a drainage bag to the end of the catheter. Remove the protective cap of the drainage bag and clean the end of the catheter and tip of the drainage bag tubing with an alcohol wipe for 15 seconds, then let dry for 15 seconds.  
        

How much to give and how often

Your child’s health-care team should provide you with a prescription that includes: 

• the dose of the concentrated tobramycin solution for instillation
  
• the amount of 0.9% normal saline to mix with the tobramycin
  
• the total volume of solution to be instilled in the bladder
  
• how long the solution should remain in your child’s bladder. 
  

How long will your child need to take tobramycin?

Speak with your child’s health-care team about the duration of your child’s tobramycin instillation therapy. 

Tobramycin storage  

• If the tobramycin vial is 80mg/2 mL, it can be used for multiple doses. The vial can be stored at room temperature for up to 28 days after opening/first use.
• Once the cap is removed, wipe the top of the tobramycin vial with an alcohol wipe for 15 seconds. Let dry for 15 seconds before withdrawing the medication.
  
• Tobramycin can be pre-mixed with normal saline and stored in the refrigerator for up to 24 hours. If refrigerated, allow it to come to room temperature before instilling.
  
• Medical grade normal saline bottles can be kept for seven days in the fridge. Ensure the lid is closed before storing. Be careful not to contaminate the container but touching or putting anything inside. Normal saline should be poured out of the container, not scooped or ladled out.
  

Can I reuse any of the supplies?

Urinary catheters, alcohol wipes, needles and luer lock syringes are single use items only. This is to limit the risk of recurrent UTIs. Remember, needles must be discarded in a sharps container. Always use new clean supplies as recommended.

Medical grade normal saline bottles can be kept for seven days in the fridge. Ensure the lid is closed before storing. Be careful not to contaminate the container but touching or putting anything inside. Normal saline should be poured out of the container, not scooped or ladled out.

Catheter caps, specimen containers and catheter tip syringes can be sterilized and re-used for up to seven days.

Cleaning catheter caps, catheter tip syringes and containers 

Catheter caps, catheter tip syringes and specimen containers should be cleaned immediately after use. 

1. Just after using the supplies, take the syringe pieces apart and wash all the items with warm water and dish soap. Rinse thoroughly two times. 
   
2. Dry with paper towel and store in a plastic bag. Sterilize them later that day as outlined below.
   

Sterilizing catheter caps, catheter tip syringes and specimen containers

1. Soak containers and syringes in a clean basin of room temperature water with 1 cup of vinegar for about 30 minutes.
   
2. Rinse containers and syringes with distilled water. 
   
   • You can boil water and have it return to room temperature before using, or you can use bottled distilled water to rinse the containers. Do not use boiling hot water on these items.
     
3. Put the items on a clean paper towel to air dry completely. Store the items in a clean zip-lock plastic bag.
   

What happens if some of the tobramycin solution leaks out of your child’s bladder?

If some of the tobramycin solution leaked out of your child’s bladder before it is time to drain it, do not repeat the instillation. Proceed with the next tobramycin instillation at the next scheduled time. Do not double the dose. 

What happens if I forgot to give the tobramycin instillation? 

Most tobramycin instillations are done once a day. If you forget to give the tobramycin instillation, give it at the time you remember. For example, if you forgot to give the tobramycin instillation at 9:00 am and you remember at 8:00 pm, you can give it at 8:00 pm. Do not double the dose.

How can I make my child more comfortable?

• Have your child sitting down during procedure.
  
• Instilling cold solution can cause painful bladder spasms. Bring the normal saline to room temperature before using it. Run the sealed container under tap water or leave the container out to warm to room temperature. 
  
• Push the syringe of normal saline slowly to prevent bladder spasms.
  

When to contact your child’s health-care team

Contact your child’s health-care team if:

• your child develops signs of an allergic reaction, such as rash.
  
• your child experiences pain or discomfort in the lower belly (suprapubic area)
  
• your child develops new symptoms of a UTI or their initial symptoms being treated by the instillations do not improve after the course of medication prescribed by your child’s health-care team 
  
• there is unexpected or new blood in your child’s urine (especially bright red blood or clots)
  
• you are unsure how to prepare or give the medication to your child
  
• you are unable to drain the tobramycin solution from your child’s bladder
  
• you have concerns about catheterization or bladder spasms. 
  

At SickKids

Supplies

Supplies may be purchased from the following places:

• The SickKids Specialty Food Shop
• CathetersPLUS (Real Life Medical)
  
• Wellwise by Shoppers Drug Mart
  
• Coloplast Canada
  
• Your local medical supply store
  

Your child’s health-care team can help you choose the right supplies and can provide you with a prescription for your child’s supplies to submit to private insurance for coverage.