Original Article Safe duration of silicon catheter replacement in urological patients Mawuenyo A. Oyortey1, Samuel A. Essoun2, Mahamudu A. Ali1, Mubarak Abdul-Rahman3, James Welbeck4, Jonathan C. B. Dakubo2 and James E. Mensah2 Ghana Med J 2023; 57(1): 66-74 doi: http://dx.doi.org/10.4314/gmj.v57i1.10 1Department of Surgery, School of Medicine, University of Health and Allied Sciences, Ho 2Department of Surgery, Korle Bu Teaching Hospital, Korle Bu, Accra 3Department of Pathology, University of Ghana Medical School, Korle Bu, Accra 4John Radcliffe Hospital, Oxford, England Corresponding author: Mawuenyo A. Oyortey E-mail: moyortey@uhas.edu.gh enyomawu@gmail.com Conflict of interest: None declared SUMMARY Objectives: This study compared the infection rates, degree of encrustation, symptoms, and complications in patients regarding the duration of urethral catheterisation (three weeks, six weeks, and eight weeks). Design: A cross-sectional study with stratified simple random sampling Setting: Urology Unit, Korle Bu Teaching Hospital Participants: One hundred and thirty-seven male patients with long-term urinary catheters Interventions: Participants were grouped into 3 weeks, 6 weeks, and 8 weeks duration of catheter replacements Primary outcomes measures: Symptoms due to the urinary catheters, urinalysis, urine and catheter tip cultures, sensitivity, and catheter encrustations were assessed. Results: Eighty-six patients had a primary diagnosis of benign prostatic hyperplasia (BPH), 35 had urethral stric- tures,13 had prostate cancer, two had BPH and urethral strictures, and one participant had bladder cancer. There was no difference in the symptoms the participants in the different groups experienced due to the urinary catheters (p > 0.05). The frequency of occurrence of complications (pyuria, p = 0.784; blocked catheter, p=0.097; urethral bleeding, p=0.148; epididymo-orchitis, p=0.769 and bladder spasms, p=1.000) showed no differences in the three groups. There was no statistical difference in the urinalysis for the three groups (p>0.05) and the degree of encrustations (3 weeks: 0.03 ± 0.06, 6 weeks: 0.11±0.27 and eight weeks: 0.12 ±0.27) with p=0.065. Conclusions: In this study, the duration of urinary catheterisation using silicone Foley’s catheters did not influence the complication and symptom rates; hence silicon catheters can be placed in situ for up to 8 weeks before replacement instead of the traditional three-weekly change. Keywords: Urinary catheterisation, biofilms, encrustations, silicon catheter, catheter complications Funding: Enterprise Computing Limited INTRODUCTION Urinary catheterisation is common in 21.2% to 30% of catheter expulsion which affect the quality of life.4 Stud- hospitalised patients.1 In nursing homes in the United ies have suggested that latex catheters are more prone to Kingdom, the overall prevalence was 9%, and the annual developing these complications than silicon catheters, es- reported global estimate of urinary catheterisation is pecially when the change duration is unknown.5 about 4 million patients.2 The insertion and use of a uri- nary catheter for more than 30 days is termed long-term In certain parts of the world, the high patient-to-urologist indwelling urinary catheterisation.3 Currently, the overall ratio and inadequate healthcare financing delay the defin- prevalence of long-term urinary catheterisation is un- itive urological interventions for patients giving rise to known, and the prevalence of urinary catheterisation spe- the increased burden of long-term catheterisation.6,7 As a cific to genito-urinary diseases in Ghana has not been result, catheter-related complications are higher. Prior to studied. Long-term catheterisation is beneficial in ob- 2012, latex catheters were the most used Foley catheters structive urological conditions. However, it is associated in the Korle Bu Teaching hospital and were changed with numerous complications such as catheter blockage, every 21 days (3 weeks). This practice was noted to be urinary leakage, urinary tract infections, encrustations, associated with an increased risk of severe catheter reac- bladder spasm, bladder cancer, urinary calculi, tissue tions, leading to long segment urethral strictures when a damage, meatal erosion, urethral injury, haematuria, and 66 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article specific batch of latex Foley catheters was used between (CLED) Agar. The catheter tip smear was plated on November 2011 and November 2012.8 blood, chocolate, and MacConkey agar smeared with thi- oglycollate broth and incubated for fastidious organisms This led to the introduction of silicone catheters, which overnight. are associated with fewer rates of complications and take longer to become blocked by encrustations.9,10 Frequent The rest of the catheter tip was cut to a thickness of changing of these catheters increases the cost to the pa- 0.3cm. Using a light microscope (ZEIS STEMI 1000) at tient and predisposes them to the risk of complications. a magnification of ×10, the catheter lumen diameter (Fig- Without standardised recommendations for catheter re- ure 1) and the width of the thickest part of the crust were placement frequency, this study aimed at determining measured using callipers (Castroviejo). The degree of how long urethral and suprapubic catheters can be left in catheter encrustation was determined as the ratio of the place without putting the patient at risk of catheter-re- width of the thickest part of the crust to the catheter lu- lated complications. men diameter. METHODS Study design and site This cross-sectional study examined 137 patients with long-term indwelling urinary catheters for various uro- logical indications changing their catheters in the Korle Bu Teaching Hospital’s catheter room over one year. Us- ing stratified simple random sampling, subjects were as- signed to one of three categories (A=3 weekly changes, B=6 weekly changes, and C=8 weekly changes) with the 3-weekly group as the control after informed consent was obtained. Patients with both urethral and suprapubic long-term sil- icon indwelling catheters, patients with obstructive urop- athy secondary to bladder outlet obstruction who were having continuous bladder drainage as part of their man- agement and required long-term catheterisation (su- prapubic or urethral), and patients with neurogenic blad- der who could not have intermittent catheterisation and were on long-term indwelling urethral or suprapubic Figure 1 Cross section of the catheter showing encrusta- catheter were eligible for the study. tions. Data collection Data Analysis A structured questionnaire was used to capture the pa- The data was entered into SPSS version 20. The relation- tient’s demographic characteristics, including the pa- ship between patient symptoms, complications, urinaly- tient’s diagnosis and the first catheterisation date. The pa- sis, urine culture, catheter tip culture, and catheter re- tient’s symptoms, including (urethral pain, suprapubic placement duration were determined using the Chi- pain, flank pain, peri-catheter leakage, retention of urine, square and Fisher’s exact tests. In addition, ANOVA was fever, penile or scrotal swellings) and any complications used to compare age, BMI, pH, and degree of encrusta- that occurred as a result of the catheterisation (urethral tion among the study categories. Statistical significance trauma, urethral bleeding, extravasation of urine, urethral was defined as a p-value of less than 0.05. discharge) were also recorded. The participant’s weight and height were measured at their presentation to the Ethical Approval catheter room, and BMI (body mass index) was calcu- Ethical approval was obtained from the College of Health lated. Sciences Ethics and Protocol Review Committee of the University of Ghana with a Protocol Identification Num- After the new catheter was inserted, a urine sample was ber: CHS-Et/M.02- P 3.4/2015-2016. collected into a sterile container, and the tip of the re- moved catheter was cut with a sterile blade on a sterile surface and placed in a sterile container for culture and sensitivity. Urine culture was done on Brilliant Green Agar (BGA) and Cysteine Lactose Electrolyte Deficient 67 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article RESULTS Table 3 Patient symptoms by the duration of catheter re- The 135 patients ranged in age from 18 to 93 years old, pl acement with an average age of 67.29 ±12.81 years (Table 1). In Duration of Catheter Replacement addition, two patients had no idea of their ages or birth P atient Symptoms 3 Weeks 6 Weeks 8 Weeks p -value n (%) n (%) n (%) dates. Table 1 describes the mean ages for the three sub- Urethral pain groups. 27.0% of the patients had hypertension, 2.2% had No 35 (35.0) 31 (31.0) 34 (34.0) 0.205 diabetes mellitus, and 3.6% had both diabetes and hyper- Yes 1 3 (35.1) 1 3 (35.1) 11 (29.7) tension; the majority (67.2%) had no co-morbidities. Suprapubic pain No 47 (37.0) 39 (30.7) 41 (32.3) 0.838 Yes 1 (10.0) 5 (50.0) 4 (40.0) Table 1 Mean ages by the duration of catheter replace- Flank pain ment No 46 (34.8) 43 (32.6) 43 (32.6) 0.668 Yes 2 (40.0) 1 (20.0) 2 (40.0) Duration N Mean ± Std. Deviation P- Peri-catheter leak- VALUE age AGE 3 weeks 48 66.15± 14.22 0.644 No 38 (35.8) 32 (30.2) 36 (34.0) 0.429 6 weeks 42 67.14 ± 10.55 Yes 10 (32.3) 12 (38.7) 9 (29.0) 8 weeks 45 68.64± 13.31 Urethral discharge Total 135 67.29 ± 12.81 No 44 (34.1) 41 (31.8) 44 (34.1) 0.578 Yes 4 (50.0) 3 (37.5) 1 (12.5) The mean body mass index was 23.81 ± 6.35 kg/m2 (Ta- Retention of urine ble 2). No 48 (35.0) 4 4 (32.1) 45 (32.8) Fever No 48 (35.6) 43 (31.9) 44 (32.6) 0.420 Table 2 Body mass index (BMI) by the duration of cath- Yes 0 (0.0) 1 (50.0) 1 (50.0) eter replacement Penile or Scrotal Duration N Mean ± Std. Deviation P-VALUE Swelling No 47 (35.6) 43 (32.6) 42 (31.8) 0.528 BMI 3 weeks 48 24.53 ± 7.07 0.297 Yes 1 (20.0) 1 (20.0) 3 (60.0) 6 weeks 44 24.25 ± 5.49 8 weeks 45 22.61 ± 6.30 Total 137 23.81 ± 6.35 Table 4: Complications of catheterisation versus dura- ti on of catheter replacement The indications for the urinary catheterisations were be- Duration of Catheter nign prostatic hypertrophy (86 patients), urethral stricture Complications of 3 weeks 6 weeks 8 weeks p-value (35 patients), prostate cancer (13 patients), combined Catheterisation urethral stricture and BPH (2 patients) and bladder carci- Urethral Bleeding n (%) n (%) n (%) No 44 (33.6) 42 (32.1) 45 (34.4) 0.148 noma (1 patient). About 70.8% of the patients had ure- Yes 4 (66.7) 2 (33.3) 0 (0.0) thral catheters, while 29.2% had suprapubic catheters. Pyuria No 11 (34.4) 9 (28.1) 12 (37.5) 0.784 The common catheter-related symptoms, as complained Yes 37 (35.2) 35 (33.3) 33 (31.4) Blocked Catheter by the patients, were urethral pain (37 patients), peri- No 48 (36.9) 41 (31.5) 41 (31.5) 0.097 catheter leakage (31 patients), suprapubic pain (10 pa- Yes 0 (0.0) 3 (42.9) 4 (57.1) tients), urethral discharge (8 patients), flank pain and Epididymo Orchi- penoscrotal swelling, five patients each, and two patients tis No 47 (34.8) 43 (31.9) 45 (33.3) 0.769 had a fever. The distribution of symptoms is represented Yes 1 (50.0) 1 (50.0) 0 (0.0) in Table 3. Bladder Spasms No 47 (34.6) 44 (32.4) 45 (33.1) 1.000 Complications Yes 1 (100.0) 0 (0.0) 0 (0.0) The recorded complications in this study following uri- nary catheterisation were urethral bleeding, urethral dis- Urinalysis charge, pyuria (which was determined as >10 pus cells Table 5 shows that the urine pH ranged between 5 and 9, on urinalysis), blocked catheter, epididymo-orchitis and with an overall mean of 7.07 ± 1.64. Microscopic haema- bladder spasms. Although there was no recorded urethral turia was present in 119 patients, 63 patients had nitrites, trauma, urethral stricture, stuck catheter, or bladder cal- 47 patients had crystals, leucocyte esterase was positive culus from the three groups, most of the patients had py- in 134 patients, 140 urine samples were positive for bac- uria (105), a blocked catheter (7) which were changed teria, and 2 urine samples showed the presence of yeast. earlier, epididymo-orchitis (2) and bladder spasms (1). Table 6 reports the urinalysis. 68 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article Table 5 Association between urine pH and duration of ca theter replacement Duration N Mean ± Std. Deviation p-value Urine culture There were 34 culture-positive urine specimens, with pH 3 weeks 48 7.06 ± 1.45 0.707 Escherichia coli being the most cultured organism (41%). 6 weeks 44 6.93 ± 2.00 The distribution of the cultured organism is shown in Fig- 8 weeks 45 7.22 ± 1.44 Total 137 7.07 ± 1.64 ure 2. Table 6 Associatio n between urinalysis and duration of catheter replacement Duration of Catheter Replacement Urinalysis 3 weeks 6 weeks 8 weeks p-value Blood/Haemoglobin n(%) n(%) n (%) + 4 (50.0) 3 (37.5) 1 (12.5) ++ 2 (33.3) 2 (33.3) 2 (33.3) +++ 8 (38.1) 5 (23.8) 8 (38.1) 0.399 ++++ 27 (32.1) 32 (38.1) 25 (29.8) Not detected 7 (38.9) 2 (11.1) 9 (50.0) Nitrite Negative 26 (35.1) 22 (29.7) 26 (35.1) Positive 2 2 (34.9) 22 (34.9) 1 9 (30.2) 0.762 Casts Cellular casts present 0 1 (100.0) 0 (0.0) (0.0) Granular casts present 2 (50.0) 0 2 (50.0) 0.784 (0.0) Not observed 46 (34.8 43 (32.6) 4 3 (32.6) Crystals Amorphous Phosphates 5 (35.7) 2 (14.3) 7 (50.0) 0 .519 Amorphous urates 1 (16.7) 1 (16.7) 4 (66.7) Amorphous urates/ triple 0 (0.0) 1 (50.0) 1 (50.0) phosphate Calcium oxalate 1 (50.0) 1 (50.0) 0 (0.0) Not observed 31 (34.4) 33 (36.7) 26 (28.9) Triple phosphate 3 (21.4) 5 (35.7) 6 (42.9) Triple phosphate/ amorphous 4 (66.7) 1 (16.7) 1 (16.7) phosphate Uric acid 3 (100.0) 0 (0.0) 0 (0.0) Leucocyte Esterase + 1 (100.0) 0 (0.0) 0 (0.0) ++ 1 (16.7) 4 (66.7) 1 (16.7) 0.210 +++ 45 (35.4) 39 (30.7) 43 (33.9) ++++ 0 (0.0) 0 (0.0) 1 (100.0) Not detected 1 (50.0) 1 (50.0) 0 (0.0) Bacteria + 4 (66.7) 0 (0.0) 2 (33.3) ++ 6 (28.6) 6 (28.6) 9 (42.9) +++ 35 (32.7) 38 (35.5) 34 (31.8) 0.376 Not observed 3 (100.0) 0 (0.0) 0 (0.0) Yeast Absent 46 (34.1) 44 (32.6) 45 (33.3) 0.329 Present 2 (100.0) 0 (0.0) 0 (0.0) Urine Culture Negative 37 (35.9) 30 (29.1) 36 (35.0) 0.405 Positive 11 (32.4) 14 (41.2) 9 (26.5) 69 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article Figure 2 Distribution of organisms cultured from the urine. Table 8a Frequency of organisms cultured Catheter tip culture: Number of organisms Organisms cultured N(%) One hundred and twenty-two catheter tips cultured one Pseudomonas aeruginosa 31(23.66) organism on the Maki roll, while that for the intra-lu- Escherichia coli 19(14.50) Providencia rettgeri 9(6.87) minal culture was 112. Eight catheter tips (Maki roll) cul- Klebsiellia pneumoniae 8(6.11) tured 2 or more organisms, and 11 intraluminal cultures Aeromonas hydrophilia 8(6.11) grew 2 or more organisms (Table 7). Burkholderia capacia 7(5.34) Enterococcus faecalis 6(4.58) Proteus mirabilis 4(3.05) Table 7 Number of organisms cultured by the duration Candida sp 4(3.05) of catheter replacement Enterobacter cloacae 4(3.05) Number of Organ- Duration of Catheter Replace- Klebsiella oxytoca 3(2.29) isms ment Morganella morganii 3(2.29) 3 weeks 6 weeks 8 weeks p- Providencia stuartii 3(2.29) MAKI ROLL Count Count Count value Pseudomonas fluorescens 3(2.29) (%) (%) (%) Raoultella ornitholytica 3(2.29) 0 2 (28.6) 2 (28.6) 3 (42.9) 0.446 Citrobacter koseri 2(1.53) Citrobacter fruendii 2(1.53) 1 44 (36.1) 37 (30.3) 41 (33.6) Pantoea sp 1(0.76) 2 or more 2 (25.0) 5 (62.5) 1 (12.5) Coagulase neg Staphylococcus 1(0.76) INTRA-LUMINAL Aeromonas salmonicidia 1(0.76) 0 6 (42.9) 4 (28.6) 4 (28.6) 0.963 Alkaligenes faecalis 1(0.76) 1 38 (33.9) 36 (32.1) 38 (33.9) Proteus vulgaris 1(0.76) 2 or more 4 (36.4) 4 (36.4) 3 (27.3) Serratia odorifera 1(0.76) Serratia marcescens 1(0.76) Enterobacter aeurogenes 1(0.76) Organisms cultured Shawanella putrefaciens 1(0.76) The most frequently cultured organisms for the external Vibrio alginolytica 1(0.76) (maki roll) and intraluminal surfaces were similar. Pseu- Achrobacter dentrifcans 1(0.76) Ochrobactrum anthropi 1(0.76) domonas aeruginosa, Escherichia coli, Providencia Table 8b Frequency of organisms at the catheter tip rettgeri, and Klebsiella pneumonia were predominant in (Maki roll) cultured (intraluminal) the cultures, although Pseudomonas aeruginosa was fre- Organisms cultured N(%) quently cultured on the external surface, while Esche- Escherichia coli 28(20.89) richia coli was commonly found in the intra-luminal sur- Pseudomonas aeruginosa 22(16.42) face (Table 8). Providencia rettgeri 11(8.21) Klebsiellia pneumoniae 10(7.46) Aeromonas hydrophilia 7(5.22) Morganella morganii 7(5.22) Proteus vulgaris 6(4.48) Enterococcus faecalis 5(3.73) Citrobacter freundii 4(2.99) Burkholderia capacia 4(2.99) Klebsiella oxytoca 3(2.24) Pantoea sp 3(2.24) 70 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article Providencia stuartii 3(2.24) diseases occurring in the younger age group and trau- Candida sp 3(2.24) matic causes occurring over varying age ranges.16 The Enerobacter cloacae 3(2.24) common causes of urinary catheterisation in patients who Raoultella ornitholytica 2(1.49) Pseudomonas fluorescens 2(1.49) presented with urine retention in Kumasi were benign Proteus mirabilis 2(1.49) prostatic hyperplasia, urethral stricture and prostate car- Enterobacter aeurogenes 1(0.75) cinoma.17 Similarly, in this study, 86 out of the 137 pa- Alkaligenes faecalis 1(0.75) tients had BPH, followed by urethral stricture and carci- Citrobacter koseri 1(0.75) Serratia odorifera 1(0.75) noma of the prostate. Serratia marcesens 1(0.75) Shawanella putrefaciens 1(0.75) In a study of urinary catheterisation in nursing homes in Ochrobactrum anthropi 1(0.75) the United Kingdom, McNulty et al. discovered that 72% Staphlococcus aereus 1(0.75) Achrobacter dentrificans 1(0.75) had urethral catheters, and the rest had suprapubic cathe- ters. 2 In comparison, in a study of patients with acute uri- Encrustations nary retention and prolonged catheterisation in Nigeria, Encrustation occurred on 35 catheter tips, and the mean 47.4% had benign prostatic enlargement (BPE) and had degree of encrustation was 0.09+ 0.22 (Table 9). urethral catheters, while 52.6% had urethral stricture dis- ease with suprapubic catheters. 6 As in the case of Table 9 Degree of encrustation and duration of catheter McNulty et al., this study had more patients with urethral replacement (70.8%) than suprapubic (29.2%) catheters. Suprapubic Duration N Mean ± Std. p-cvaltuhe terisation has been shown to be more comfortable Deviation than urethral catheters, and there is less risk of urethral DEGREE OF EN- 3 weeks 48 0.03± 0.06 0.0in65ju ry and urethritis.18 However, no statistically signifi- CRUSTATION 6 weeks 44 0.11 ±0.27 cant difference existed between the catheterisation type 8 weeks 45 0.12± 0.27 Total 137 0.09 ± 0.22 and the catheter replacement duration. A p-value of 0.072 indicates that the type of catheterisation was not a con- DISCUSSION founding factor in the symptoms and complications ex- perienced by the patients in the three groups. Urinary catheterisation is one of the most common pro- cedures performed in the urology unit, but it is not with- The common problems or symptoms patients with long- out risks, which vary depending on the catheterisation term catheterisation experienced included urethral pain, technique, the length of time the catheter has been in suprapubic pain, peri-catheter leakage, urethral dis- place, the type of catheter material used, and the patient’s charge, fever and penoscrotal swelling. In this study, co-morbidities, among other factors. This study evalu- 27% of the patients had urethral pain, 22.63% had peri- ated the dangers of leaving the catheter in-situ for up to catheter leakage, 7.30% had suprapubic pain, 5.84% had two months. urethral discharge, 3.65% had penoscrotal swelling, 1.46% had a fever. Several studies showed similar symp- Some infection control programs have recognised that toms in patients with long-term urinary catheterisa- routinely changing urinary catheters when there is no in- tion.14,19 Similarly, in Nigeria, another study discovered dication (infection or blockage) increases the risk of uri- 11 that 69.4% of 62 patients with prolonged catheterisation nary tract infections. Most practices followed the man- had urethral/suprapubic pain, 32.3% had urethral bleed- ufacturer’s 30-day recommendation, contrary to best ing, and 61% had peri-catheter leakage.20 Even though practices.11,12 Wilson, after reviewing the evidence per- these symptoms were present, the study showed that the taining to nursing actions for the prevalence of catheter- duration of catheter replacement did not influence the oc- associated urinary tract infection (CAUTI) with short and currence of these symptoms. Changing the catheter at 3 long-term catheterisation, stated that the recommended weeks or 8 weeks did not increase the incidence of these time between catheter replacement depends on local pol- symptoms. icies and varies between one and three months.13 Other complications experienced by the participants in Studies have shown that patients on long-term urinary this study included urethral bleeding, urethral discharge, catheterisation because of conditions such as urethral pyuria, blocked catheter, epididymo-orchitis, and bladder strictures, prostatic diseases, and other urological condi- spasms. Stuck catheters, urethral strictures, and calculus tions cover a widely diverse age range, as shown in this 14,15 were not seen in this study because these complications study (18-93 years). Depending on the cause, urethral occur in patients who fail to change their catheters and strictures occur in people of varying ages, with inflam- keep them in for longer than necessary, as reported by matory or infectious causes from sexually transmitted Miason and Yenli, who reported two cases of vesical cal- 71 www.ghanamedj.org Volume 57 Number 1 March 2023 Copyright © The Author(s). This is an Open Access article under the CC BY license. Original Article culus after keeping their suprapubic and urethral cathe- ters for 5 and 2 years, respectively.21 There was no iatro- The mean pH for all the groups is less acidic than the genic injury, which may be because trained nurses normal urine pH (6.0). The presence of urea-producing changed the urethral catheters. bacteria in the urine, which make the urine less acidic than normal, also causes the build-up and deposition of Bacteriuria is the most obvious evidence of urinary tract salts, increasing crusts around the catheter and stone for- infection.22 Catheter-associated bacteriuria is defined by mation. The role of urease-producing organisms in the the presence of ≥105 cfu/mL of ≥1 bacterial species in a formation of bladder stones and crusts on catheters result- single catheter urine specimen in patients without symp- ing in blockage, has been shown in several publications. toms. For CAUTI, the patient should have symptoms 28,29,30 with no other source of infection and ≥105 cfu/mL of ≥1 bacterial species.23 Pyuria and leukocyte esterase indicate Finally, looking at the mean encrustation rates of the 3 inflammation, which may occur even in the absence of groups, the 3 weeks group had a mean of 0.02 ± 0.59, the infection (low specificity and positive predictive value), 6 weeks group 0.11 ± 0.27 and the 6 weeks group 0.12 ± but its absence rules out an infection.24 Nitrites occur in 0.27. The mean degree of encrustation increased as the urine when nitrate-reducing bacteria are present in the duration of the catheter stayed in place because the longer urine. Because not all organisms reduce nitrates in urine, the catheter was in place, the more mineral content dep- the absence of nitrites does not rule out an infection. The osition on the catheter surface occurred, but this was not duration of catheterisation has been determined to be the statistically significant. most important determinant of bacteriuria with a daily risk of 3-7%.25 Bacteriuria is reported as ‘few’ (+), ‘mod- CONCLUSION erate’ (++), or ‘many’ (+++). In this study, bacteriuria There was no difference in patient symptoms, complica- was present in all the urine specimens analysed. The tions, urinalysis, urine cultures, catheter tip and encrusta- urine cultured bacteria in 34 (24.82%) and yeast in 2 tion rates between the 3 weeks, 6 weeks, and 8 weeks urine samples. The difference between the groups was groups of patients catheterised with the full silicone cath- not statistically significant. Most urine cultures did not eter. Therefore, we propose that catheters be left in place grow pathogenic bacteria, probably because some partic- for patients undergoing long-term catheterisation using ipants may have been on antibiotics. However, some pure silicon catheters for up to 8 weeks before being showed mixed growth, probably from contamination, and changed. it would have been ideal to repeat the urine cultures. ACKNOWLEDGEMENT As expected, the catheter tip cultured more organisms The authors would like to acknowledge the staff and pa- than the urine samples. Studies have shown that although tients of the Urology unit at Korle Bu Teaching Hospital. multiple bacteria can be detected on the catheter tip, only a small fraction would be determined in traditional mi- REFERENCES crobiological cultures.26 The importance of organisms 1. Jansen IAV, Hopmans TEM, Wille JC, van den Broek found in the biofilm that coats the catheter surface is that PJ, van der Kooi TII, van Benthem BHB. Appropriate they are less susceptible to antibiotics because of the pro- use of indwelling urethra catheters in hospitalised pa- tective layer of the biofilm and the fact that organisms tients: results of a multicenter prevalence study. 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