This is a cross-sectional study conducted among patients who had catheter inserted into urinary bladder from November 2015 to April 2016.

Tamale Teaching Hospital, an 800 bed capacity tertiary hospital in Tamale, Northern Region, Ghana.

From November 2015 to April 2016, a cross sectional study was undertaken at the urology clinic of the Tamale Teaching Hospital of Ghana. The eligibility criteria included patients who had catheter in situ and who consented to be part of the study. We excluded, immunosuppressed patients, non-catheterized patients, those who had confirmed UTI just preceding this study, those taking antibiotic prophylaxis prior to catheterization and those who declined consent.

Eligible patients who consented to be part of the study were assigned unique Identification (Id) numbers. Data was recorded on a well-designed sheet. Data fields included: age, sex, address marital status and indication for catheterization.

A spigot was placed at tip of catheter and opened when the patient experienced the sensation to void, associated with a suprapubic mass, which was indicative of a full bladder. The spigot was then removed to allow about 10 - 20 ml of urine to flow through and drop off. This was to ensure clean urine was obtained devoid of contamination. Urine collection was done under aseptic conditions into a sterile, dry, leak-proof container. About 2 - 5 ml was collected from the tip of catheter. The containers were labeled with the patient’s identification number, age, sex, date and the time of collection. The urine specimen was transported together with the data collection form and delivered to the bacteriology laboratory for culture, biochemical tests, isolation and antibiotic susceptibility tests.

Using a sterile calibrated wire loop and under aseptic conditions, about 0.01 ml of urine was inoculated onto a prepared agar plate of Cystine Lactose Electrolyte Deficient (CLED). The plate was incubated under aerobic conditions at 37˚C for 24 hours and observed for bacteria growth. Significant growth of >10⁵ bacteria/ml of catheter urine was interpreted as a colony of bacteria with a viable count [19]. Bacteria colonies were identified using colony growth characteristics and Gram staining as well as standard biochemical testing procedures which included indole, urea, triple sugar Iron (TSI), motility and citrate tests were all carried out in accordance with Monica Chessbrough [20].

An emulsification was made in bijou bottle containing 5 ml peptone water with the pure colonies, until the turbidity was equal to the 0.5 McFarland standards. An approximately 200 µl/loopful of the suspension was dispensed to the center of 25 ml Muller-Hinton culture plate and seeded carefully with the sterile swab stick in three directions to obtain even growth on the Muller-Hinton agar surface, allowing the moisture to be absorbed for at least 15minutes. Using the disc diffusion method of antimicrobial susceptibility test, the urine antibiotics multi-discs (manufactured by Axiom Laboratories, India) were applied firmly to the surface of the Mueller-Hinton agar plate. The antibiotics multidisc comprised of Ampicillin (AMP, 20 mcg), Ceftizoxime (CL, 30 mcg), Ciprofloxacin (CP, mcg), Amikacin (AMK, 30 mcg), Cotrimoxazole (BA, 25 mcg), Cephalexin (PR, 30 mcg), Tetracycline (TE, 30 mcg), Levofloxacin (LE, 5 mcg), Ofloxacin (OF, 5 mcg), Norfloxacin (NX, 10 mcg), Chloramphenicol (CH, 30 mcg), Sparfloxacin (SC, 5 mcg), Gentamicin (GEN, 30 mcg), Ceftriaxone (CTR, 30 mcg), Cefuroxime (30 mcg).

The set-up was incubated aerobically at 37˚C for 18 - 24 hrs, after which it was inspected for bacteria growth and growth inhibition. The diameter of the zone of growth inhibition around each antimicrobial agent was measured and compared with the NCCLS interpretive table, NCCLS, 1997 to determine bacterial sensitivity or resistance to each of the antimicrobial agents used [21]. Standard commercial bacteria strains comprising of Staphylococcus aureus NCTC 6571, Escherichia coli NCTC 10418 and Pseudomonas aeruginosa NCTC 10662 were used as control.

Data was entered into Microsoft excel spreadsheet windows 7 and checked for data entry errors. Data analysis was carried out using IBM SPSS version 21 statistical package. Associations between variables were determined with level of significance set at p < 0.05.

Urine culture test has been used over decades for diagnosing patients who have UTI. The identification of CABUTI uropathogens and the antibiotic susceptibility patterns enable practitioners select the appropriate antibiotics for treatment. Escherichia coli, the leading uropathogen in urine cultures and other Enterobacteriaceae, account for approximately 75% of all uropathogens [24] [25] [26]. Included in the top five uropathogens were Escherichia coli 30.5%, Klebsiella pneumoniae 30.5%, Pseudomonas aeruginosa 16.6% and Candida spp. 16.6% as reported by Kazi and colleaques [27]. This present study revealed that Escherichia coli 46.6%, Klebsiella spp. 20.6%, Pseudomonas spp. 11.4%, Enterobacter 6.8% and Staphylococcus aureus 5.8% respectively were the most prevalent CABUTI uropathogens at the Tamale Teaching Hospital. The least prevalent CABUTI uropathogens were Citrobacter diversus, Morganella morgani, Enterococcus spp., Klebsiellao xytoca, Streptococcus spp., Proteus mirabilis and Candida albicans each constituting 1 (1.1%). These organisms are mainly endogenous bowel flora. Thus, poor personal hygiene or non-adherence to aseptic technique during catheterization could account for the higher prevalence of these organisms in the urine of our study participants. It has been established that CABUTI is one of the health care associated infections that may be contracted through contact with contaminated equipment or solutions and from other patients or hospital staff [23] [28] [29].

Antibiotic use by patients prior to presentation of urine samples could significantly alter microbial yield and consequently prediction of infection rates because they suppress the endogenous bacteria flora [30] [31]. Multiple studies have demonstrated resistance to a host of antibiotics including ampicillin, chloramphenicol, cotrimoxazole, gentamicin, cefuroxime [30] [32] [33]. This phenomenon of drug resistance differs from one place to another. Though there is antimicrobial resistance to a large extend, some studies show there were susceptibility of uropathogens to some antibiotics. In Ghana, Gyansa-Lutterodt and associates found high susceptibility of uropathogens to Nitrofuantoin and Gentamicin at the Police Hospital, while Gyasi-Sarpong et al reported susceptibility of uropathogens to ciprofloxacin, nalidixic acid, cefuroxime, ceftriaxone and cefotaxime at the Komfo Anokye Teaching Hospital [30] [32]. In order of decreasing susceptibility, we report that Amikacin 83.0%, Levofloxacin 38.6% and Ciprofloxacin 29.5% were the antibiotics found to be most suitable in treatment of urinary tract infection at the Tamale Teaching Hospital. The existence of substantial resistance of bacterial isolates to antibiotics is therefore implied. This might be as a result of indiscriminate usage of these antibiotics resulting in resistance among the bacterial isolates. The bacterial isolates showed least susceptibility to Cefuroxime 1.1%, Ampicillin 3.4% and Gentamicin 3.4% in order of increasing susceptibility. Other antibiotics with least sensitivity were Co-trimoxazole 8.0%, Norfloxacin 8.0%, Cephalexin 9.1%, Sparfloxacin 14.8%, Chloramphenicol 23.9% and Ofloxacin 25.0% in order of increasing susceptibility. It is important for practicing clinicians to appraise their knowledge on the local antibiotics’ susceptibility patterns so as to effectively treat CABUTI.

This study had some limitations. Firstly, the duration of catheterization preceding sample collection for urine culture and sensitivity was not established. Secondly, the participants were not grouped into either catheter associated bacteriuria (asymptomatic) and catheter associated urinary tract infection (symptomatic). For catheter associated bacteriuria (asymptomatic), no treatment is usually needed. This is an important point to consider in determining antibiotic susceptibility and recommending treatment.