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Emergence of extended-spectrum β-lactamase-producing Escherichia coli in catheter-associated urinary tract infection in neurogenic bladder patients
American Journal of Infection Control 42 (2014) e29-e31
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Emergence of extended-spectrum b-lactamase-producing Escherichia coli in catheter-associated urinary tract infection in neurogenic bladder patients Kei Takaba BS a, Katsumi Shigemura MD, PhD b, c, *, Kayo Osawa PhD c, Masashi Nomi MD, PhD d, Masato Fujisawa MD, PhD b, Soichi Arakawa MD, PhD b, c a
Department of Clinical Laboratory, Hyogo Prefectural Rehabilitation Center, Kobe, Japan Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan Infection Control Team, Kobe University Hospital, Kobe, Japan d Department of Urology, Hyogo Prefectural Rehabilitation Hospital, Kobe, Japan b c
Key Words: Catheter-associated urinary tract infection (CAUTI) Extended-spectrum b-lactamase (ESBL)producing Escherichia coli Repetitive-sequence-based polymerase chain reaction (rep-PCR)
Background: Catheter-associated urinary tract infection (CAUTI) is a common clinic problem. The purpose of this study was to investigate recent trends in CAUTI in neurogenic bladder patients focusing on extended-spectrum b-lactamase (ESBL)-producing Escherichia coli. Methods: Isolates from the urine of neurogenic bladder patients with UTI were investigated. Nine strains of ESBL-producing E coli were assayed by molecular strain typing using the Diversilab system for repetitive-sequence-based polymerase chain reaction (rep-PCR). Results: E coli accounted for most of the bacteria (74.1% to 81.0%) that produced ESBLs. Rep-PCR data showed that 7 out of 9 ESBL-producing E coli belonged to the same typing group with high similarity (more than 97% similarity) and that this distribution corresponded with antibiotic resistance patterns. Conclusion: ESBL producing E coli strains isolated from CAUTI patients could be discriminated by rep-PCR typing using the Diversilab system in consistent with antibiotic resistance patterns. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Studies of increasing prevalence of resistant strains in urinary tract infection (UTI) have noted that catheter-associated UTI (CAUTI) has different trends in causative bacteria from non-CAUTI.1,2 In both, Escherichia coli is a representative causative bacteria and sometimes represent resistance to antibiotics such as extended-spectrum blactamase (ESBL)-producing E coli.3,4 Such resistant strains need to be monitored closely in hospitalized infections to prevent their spread,5,6 and epidemiologic analyses are critical for detecting and preventing the emergence of this kind of strain. Repetitive-sequence-based polymerase chain reaction (rep-PCR) using the Diversilab system (bioMérieux, Marcy l’Etoile, France) is rapid, noncomplex, and cost-effective. It has the advantage of being less labor intensive than pulse-field gel electrophoresis.7-10 In this study, we investigated recent causative bacteria including ESBL-producing E coli in CAUTI of neurogenic bladder patients and applied rep-PCR the Diversilab system for epidemiologic analyses. * Address correspondence to Katsumi Shigemura, MD, PhD, Division of Urology, Department of Organs Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. E-mail address: [email protected] (K. Shigemura). Conflicts of interest: None to report.
METHODS Isolates From 2006 to 2009, a total of 1,108 urine samples was cultured for the diagnosis of suspicious CAUTI patients who presented UTI symptoms such as fever or lower abdominal or back pain with neurogenic bladder in Hyogo Prefectural Rehabilitation Hospital. The isolated bacteria were taken from 105 or more colony-forming units/mL in urines. Susceptibilities to antibiotics Susceptibility testing was performed for 12 kinds of antibiotics such as sulbactam/ampicillin and cefozopran according to Clinical and Laboratory Standards Institute criteria.11 ESBL detection ESBL-producing bacteria were diagnosed with a positive ESBL screen test. Results were considered positive with formation of inhibition zone by clavulanic acid on the middle amoxicillin/clavulanic acid disc surrounded by the discs of cefotaxime, cefotaxime/clavulanic
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.11.018
e30
K. Takaba et al. / American Journal of Infection Control 42 (2014) e29-e31
Table 1 Isolated ESBL-producing bacteria from CAUTI Bacteria Escherichia coli Klebsiella pneumoniae Klebsiella oxytoca Proteus mirabilis Total
2006, n (%) 7 (77.7) 2 (22.2) 0 0 9
2007, n (%) 20 4 2 1
(74.1) (14.8) (7.41) (3.70) 27
2008, n (%) 15 2 1 1
2009, n (%)
r
P value
17 (81.0) 4 (19.0) 0 0 21
0.656 0.353 0.072 0.077
.344 .647 .928 .923
(78.9) (10.5) (5.26) (5.26) 19
b 0.293 0.090 0.025 0.037
b, regression coefficient; ESBL, extended-spectrum b-lactamase; r, correlation coefficient.
Fig 1. Strain differentiation of ESBL-producing E coli isolate using the Diversilab system of auto matched repetitive-sequence-based PCR. ECKR 11-19 showed different samples from different patients; and ECKR 20 was the same as ECKR 11, and ECKR 21 was same as ECKR 12. These different 9 (ECKR 11-19) samples were classified to 3 clusters with 97% similarities.
acid, ceftazidime, cefpodoxime, aztreonum, and piperacillin based on the double disc synergy test.12 Rep-PCR The ESBL strains were subcultured in 5% sheep blood agar medium with 48 hours of incubation. The agar plates were processed for genomic DNA extraction and preparation using the UltraClean microbial DNA isolation kit (bioMérieux). Rep-PCR amplification was performed according to the manufacturer’s instructions (bioMérieux). The amplified rep-PCR products analyzed by DiversiLab analysis software (version 3.4; bioMérieux) for a genealogic tree formation. Statistical analysis Statistical analyses were conducted by Student t and c2 test with JSTAT-Java Virtual Machine Statistics Monitoring Tool (Sun Microsystems, Inc, Santa Clara, CA) and linear regression analysis especially for distribution of ESBL-producing bacteria in 4 years with the PASW Statistics 17.0 software package (for Windows; SPSS Inc, Chicago, IL). Statistical significance was established at the .05 level.
Enterococcus faecalis, Klebisiella pneumoniae, or methicillinresistant Staphylococcus aureus. The ratio of E coli isolation was 27.4%, 30.0%, 31.0%, and 35.3% in 2006, 2007, 2008, and 2009, respectively (data not shown). ESBL distribution ESBL-producing bacteria were isolated in 9, 27, 19, and 21 cases in 2006, 2007, 2008, and 2009, respectively. Especially, ESBLproducing E coli represented most frequently isolated, followed by K pneumoniae, and this trend was not changed in 4 years (Table 1). The ESBL-producing E coli isolated ratio in all the E coli isolated tended to be greater (20.0% to 31.0%) in nosocomial cases than community-acquired cases (13.0% to 25.0%) from 2006 to 2010, but this difference was not statistically significant (P > .05). Rep-PCR
RESULTS
The results showed that our 9 strains were discriminated into 3 groups based on their similarities and that 7 strains were categorized as the same typing with high similarity (more than 97%). Importantly, this rep-PCR discrimination corresponded with antibiotic resistance patterns (Fig 1).
Bacterial isolates
DISCUSSION
In the 4-year study period, 1,524 causative bacteria specimens from the urines of CAUTI patients were isolated. In detail, E coli was the most often isolated followed by Pseudonomas aeruginosa,
Neurogenic bladder patients often have dysfunctional voiding or storage13 and residual urines, resulting in the presence of pyuria or bacteriuria. Many of these patients need to be catheterized for
K. Takaba et al. / American Journal of Infection Control 42 (2014) e29-e31
urinary retention.14-16 These patients are at risk for CAUTI owing to catheter problems such as occlusion allowing bacterial colonization to become bacterial infection.1-3 It is controversial whether CAUTI shows a different trend in causative bacteria from non-CAUTI. Our previous study showed that CAUTI might have different trends in bacterial isolation and antibiotic susceptibilities than non-CAUTI: for instance, the susceptibilities to levofloxacin in E faecalis in CAUTI patients were significantly lower than in noncatheterized UTI,3 and the ratio of E coli isolation was comparatively lower and that of methicillin-resistant Staphylococcus aureus was also lower. We interpret these findings as follows: (1) Catheters may have biofilms that lead to the microbial substitution phenomenon16; and (2) CAUTI patients may have a history of previous antibiotic use, and resistant strains may remain in their system. Regarding ESBLs, CAUTIs have a greater chance to have ESBLproducing bacteria than non-CAUTI,17 and this could be explained by the presence of a urinary catheter by the formation of biofilms as a risk factor for UTIs because of gram-negative bacteria, regardless of the resistance pattern.13 A survey in France indicated that the incidence of ESBL-producing isolates/1,000 hospitalization-days had increased 4-fold over 10 years.18 Rep-PCR has the advantageous features of reproducibility for bacterial typing19 and provides higher consistency and accuracy than pulse-field gel electrophoresis and has been used for epidemiologic analyses of ESBL UTI (E coli or K pneumonia).20 We showed that 7 out of 9 tested strains were clustered with high similarity and that this distribution corresponded with the antibiotic susceptibility pattern but not with the isolated time course or the patients’ ward. We would like to emphasize the study limitations. First, the number of isolated bacteria in CAUTI varied in each year. Results may be affected by the number of CAUTI or by the physicians’ discretion. Second, we lacked information on patients’ clinical backgrounds. Third, this study has the retrospective nature. Fourth, the represented data were comparatively older, but we will continue this kind of study for update. These limitations including lack of patients’ background information will be overcome in our future studies. In conclusion, our findings demonstrate that E coli was the most common bacteria found among ESBL-producing bacteria in CAUTI of neurogenic bladder patients and that they could be discriminated by typing with rep-PCR using the Diversilab system. References 1. Milan PB, Ivan IM. Catheter-associated and nosocomial urinary tract infections: antibiotic resistance and influence on commonly used antimicrobial therapy. Int Urol Nephrol 2009;41:461-4.
e31
2. Bi XC, Zhang B, Ye YK, He HC, Han ZD, Dai QS, et al. Pathogen incidence and antibiotic resistance patterns of catheter-associated urinary tract infection in children. J Chemother 2009;21:661-5. 3. Yamamichi F, Shigemura K, Matsumoto M, Nakano Y, Tanaka K, Arakawa S, et al. Relationship between urinary tract infection categorization and pathogens’ antimicrobial susceptibilities. Urol Int 2012;88:198-208. 4. Kariuki S, Revathi G, Corkill J, Kiiru J, Mwituria J, Mirza N, et al. Escherichia coli from community-acquired urinary tract infections resistant to fluoroquinolones and extended-spectrum b-lactams. Infect Dev Ctries 2007;1:257-62. 5. Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005;22:627-39. 6. Wagenlehner FM, Vahlensieck W, Bauer HW, Weidner W, Piechota HJ, Naber KG. Prevention of recurrent urinary tract infections. Minerva Urol Nefrol 2013;65:9-20. 7. Church DL, Chow BL, Lloyd T, Gregson DB. Comparison of automated repetitivesequence-based polymerase chain reaction and spa typing versus pulsed-field gel electrophoresis for molecular typing of methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2011;69:30-7. 8. Hirvonen JJ, Pasanen T, Tissari P, Salmenlinna S, Vuopio J, Kaukoranta SS. Outbreak analysis and typing of MRSA isolates by automated repetitivesequence-based PCR in a region with multiple strain types causing epidemics. Eur J Clin Microbiol Infect Dis 2012;31:2935-42. 9. Ross TL, Merz WG, Farkos M, Carroll KC. Comparison of an automated repetitive sequence-based PCR microbial typing system to pulsed-field gel electrophoresis for analysis of outbreaks of methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2005;43:5642-7. 10. Deplano A, Denis O, Rodriguez-Villalobos H, De Ryck R, Struelens MJ, Hallin M. Controlled performance evaluation of the DiversiLab repetitive-sequencebased genotyping system for typing multidrug-resistant health careassociated bacterial pathogens. J Clin Microbiol 2011;49:3616-20. 11. Clinical and Laboratory Standards Institute. Performance standards for antimicrobials susceptibility testing; nineteenth Informational supplement 2009. M100-S19. Wayne [PA]: Clinical and Laboratory Standards Institute; 2009. 12. Ho PL, Chow KH, Yuen KY, Ng WS, Chan PY. Comparison of a novel, inhibitorpotentiated disc-diffusion test with other methods for the detection of extended-spectrum b-lactamases in Escherichia coli and Klebsiella pneumoniae. J Antimicrob Chemother 1998;42:49-54. 13. Buckley B, Grant AM. What is the most effective management of neurogenic bladder dysfunction? BMJ 2009;338:b659. 14. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008;77:643-50. 15. Ko YH, Kim JW, Kang SG, Jang HA, Kang SH, Park HS, et al. The efficacy of inand-out catheterization as a way of trial without catheterization strategy for treatment of acute urinary retention induced by benign prostate hyperplasia: variables predicting success outcome. Neurourol Urodyn 2012;31:460-4. 16. Niveditha S, Pramodhini S, Umadevi S, Kumar S, Stephen S. The isolation and the biofilm formation of uropathogens in the patients with catheter-associated urinary tract infections (UTIs). J Clin Diagn Res 2012;6:1478-82. 17. Tinelli M, Cataldo MA, Mantengoli E, Cadeddu C, Cunietti E, Luzzaro F, et al. Epidemiology and genetic characteristics of extended-spectrum b-lactamaseproducing gram-negative bacteria causing urinary tract infections in long-term care facilities. J Antimicrob Chemother 2012;67:2982-7. 18. Nicolas-Chanoine MH, Jarlier V. Extended-spectrum b-lactamases in longterm-care facilities. Clin Microbiol Infect 2008;14:S111-6. 19. Trindade PA, McCulloch JA, Oliveira GA, Mamizuka EM. Molecular techniques for MRSA typing: current issues and perspectives. Braz J Infect Dis 2003;7:32-43. 20. de Cueto M, Hernández JR, López-Cerero L, Morillo C, Pascual A. Activity of osfomycin against extended-spectrum b-lactamase producing Escherichia coli and Klebsiella pneumoniae. Enferm Infecc Microbiol Clin 2006;24:613-6.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Emergence of extended-spectrum b-lactamase-producing Escherichia coli in catheter-associated urinary tract infection in neurogenic bladder patients Kei Takaba BS a, Katsumi Shigemura MD, PhD b, c, *, Kayo Osawa PhD c, Masashi Nomi MD, PhD d, Masato Fujisawa MD, PhD b, Soichi Arakawa MD, PhD b, c a
Department of Clinical Laboratory, Hyogo Prefectural Rehabilitation Center, Kobe, Japan Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan Infection Control Team, Kobe University Hospital, Kobe, Japan d Department of Urology, Hyogo Prefectural Rehabilitation Hospital, Kobe, Japan b c
Key Words: Catheter-associated urinary tract infection (CAUTI) Extended-spectrum b-lactamase (ESBL)producing Escherichia coli Repetitive-sequence-based polymerase chain reaction (rep-PCR)
Background: Catheter-associated urinary tract infection (CAUTI) is a common clinic problem. The purpose of this study was to investigate recent trends in CAUTI in neurogenic bladder patients focusing on extended-spectrum b-lactamase (ESBL)-producing Escherichia coli. Methods: Isolates from the urine of neurogenic bladder patients with UTI were investigated. Nine strains of ESBL-producing E coli were assayed by molecular strain typing using the Diversilab system for repetitive-sequence-based polymerase chain reaction (rep-PCR). Results: E coli accounted for most of the bacteria (74.1% to 81.0%) that produced ESBLs. Rep-PCR data showed that 7 out of 9 ESBL-producing E coli belonged to the same typing group with high similarity (more than 97% similarity) and that this distribution corresponded with antibiotic resistance patterns. Conclusion: ESBL producing E coli strains isolated from CAUTI patients could be discriminated by rep-PCR typing using the Diversilab system in consistent with antibiotic resistance patterns. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Studies of increasing prevalence of resistant strains in urinary tract infection (UTI) have noted that catheter-associated UTI (CAUTI) has different trends in causative bacteria from non-CAUTI.1,2 In both, Escherichia coli is a representative causative bacteria and sometimes represent resistance to antibiotics such as extended-spectrum blactamase (ESBL)-producing E coli.3,4 Such resistant strains need to be monitored closely in hospitalized infections to prevent their spread,5,6 and epidemiologic analyses are critical for detecting and preventing the emergence of this kind of strain. Repetitive-sequence-based polymerase chain reaction (rep-PCR) using the Diversilab system (bioMérieux, Marcy l’Etoile, France) is rapid, noncomplex, and cost-effective. It has the advantage of being less labor intensive than pulse-field gel electrophoresis.7-10 In this study, we investigated recent causative bacteria including ESBL-producing E coli in CAUTI of neurogenic bladder patients and applied rep-PCR the Diversilab system for epidemiologic analyses. * Address correspondence to Katsumi Shigemura, MD, PhD, Division of Urology, Department of Organs Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. E-mail address: [email protected] (K. Shigemura). Conflicts of interest: None to report.
METHODS Isolates From 2006 to 2009, a total of 1,108 urine samples was cultured for the diagnosis of suspicious CAUTI patients who presented UTI symptoms such as fever or lower abdominal or back pain with neurogenic bladder in Hyogo Prefectural Rehabilitation Hospital. The isolated bacteria were taken from 105 or more colony-forming units/mL in urines. Susceptibilities to antibiotics Susceptibility testing was performed for 12 kinds of antibiotics such as sulbactam/ampicillin and cefozopran according to Clinical and Laboratory Standards Institute criteria.11 ESBL detection ESBL-producing bacteria were diagnosed with a positive ESBL screen test. Results were considered positive with formation of inhibition zone by clavulanic acid on the middle amoxicillin/clavulanic acid disc surrounded by the discs of cefotaxime, cefotaxime/clavulanic
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.11.018
e30
K. Takaba et al. / American Journal of Infection Control 42 (2014) e29-e31
Table 1 Isolated ESBL-producing bacteria from CAUTI Bacteria Escherichia coli Klebsiella pneumoniae Klebsiella oxytoca Proteus mirabilis Total
2006, n (%) 7 (77.7) 2 (22.2) 0 0 9
2007, n (%) 20 4 2 1
(74.1) (14.8) (7.41) (3.70) 27
2008, n (%) 15 2 1 1
2009, n (%)
r
P value
17 (81.0) 4 (19.0) 0 0 21
0.656 0.353 0.072 0.077
.344 .647 .928 .923
(78.9) (10.5) (5.26) (5.26) 19
b 0.293 0.090 0.025 0.037
b, regression coefficient; ESBL, extended-spectrum b-lactamase; r, correlation coefficient.
Fig 1. Strain differentiation of ESBL-producing E coli isolate using the Diversilab system of auto matched repetitive-sequence-based PCR. ECKR 11-19 showed different samples from different patients; and ECKR 20 was the same as ECKR 11, and ECKR 21 was same as ECKR 12. These different 9 (ECKR 11-19) samples were classified to 3 clusters with 97% similarities.
acid, ceftazidime, cefpodoxime, aztreonum, and piperacillin based on the double disc synergy test.12 Rep-PCR The ESBL strains were subcultured in 5% sheep blood agar medium with 48 hours of incubation. The agar plates were processed for genomic DNA extraction and preparation using the UltraClean microbial DNA isolation kit (bioMérieux). Rep-PCR amplification was performed according to the manufacturer’s instructions (bioMérieux). The amplified rep-PCR products analyzed by DiversiLab analysis software (version 3.4; bioMérieux) for a genealogic tree formation. Statistical analysis Statistical analyses were conducted by Student t and c2 test with JSTAT-Java Virtual Machine Statistics Monitoring Tool (Sun Microsystems, Inc, Santa Clara, CA) and linear regression analysis especially for distribution of ESBL-producing bacteria in 4 years with the PASW Statistics 17.0 software package (for Windows; SPSS Inc, Chicago, IL). Statistical significance was established at the .05 level.
Enterococcus faecalis, Klebisiella pneumoniae, or methicillinresistant Staphylococcus aureus. The ratio of E coli isolation was 27.4%, 30.0%, 31.0%, and 35.3% in 2006, 2007, 2008, and 2009, respectively (data not shown). ESBL distribution ESBL-producing bacteria were isolated in 9, 27, 19, and 21 cases in 2006, 2007, 2008, and 2009, respectively. Especially, ESBLproducing E coli represented most frequently isolated, followed by K pneumoniae, and this trend was not changed in 4 years (Table 1). The ESBL-producing E coli isolated ratio in all the E coli isolated tended to be greater (20.0% to 31.0%) in nosocomial cases than community-acquired cases (13.0% to 25.0%) from 2006 to 2010, but this difference was not statistically significant (P > .05). Rep-PCR
RESULTS
The results showed that our 9 strains were discriminated into 3 groups based on their similarities and that 7 strains were categorized as the same typing with high similarity (more than 97%). Importantly, this rep-PCR discrimination corresponded with antibiotic resistance patterns (Fig 1).
Bacterial isolates
DISCUSSION
In the 4-year study period, 1,524 causative bacteria specimens from the urines of CAUTI patients were isolated. In detail, E coli was the most often isolated followed by Pseudonomas aeruginosa,
Neurogenic bladder patients often have dysfunctional voiding or storage13 and residual urines, resulting in the presence of pyuria or bacteriuria. Many of these patients need to be catheterized for
K. Takaba et al. / American Journal of Infection Control 42 (2014) e29-e31
urinary retention.14-16 These patients are at risk for CAUTI owing to catheter problems such as occlusion allowing bacterial colonization to become bacterial infection.1-3 It is controversial whether CAUTI shows a different trend in causative bacteria from non-CAUTI. Our previous study showed that CAUTI might have different trends in bacterial isolation and antibiotic susceptibilities than non-CAUTI: for instance, the susceptibilities to levofloxacin in E faecalis in CAUTI patients were significantly lower than in noncatheterized UTI,3 and the ratio of E coli isolation was comparatively lower and that of methicillin-resistant Staphylococcus aureus was also lower. We interpret these findings as follows: (1) Catheters may have biofilms that lead to the microbial substitution phenomenon16; and (2) CAUTI patients may have a history of previous antibiotic use, and resistant strains may remain in their system. Regarding ESBLs, CAUTIs have a greater chance to have ESBLproducing bacteria than non-CAUTI,17 and this could be explained by the presence of a urinary catheter by the formation of biofilms as a risk factor for UTIs because of gram-negative bacteria, regardless of the resistance pattern.13 A survey in France indicated that the incidence of ESBL-producing isolates/1,000 hospitalization-days had increased 4-fold over 10 years.18 Rep-PCR has the advantageous features of reproducibility for bacterial typing19 and provides higher consistency and accuracy than pulse-field gel electrophoresis and has been used for epidemiologic analyses of ESBL UTI (E coli or K pneumonia).20 We showed that 7 out of 9 tested strains were clustered with high similarity and that this distribution corresponded with the antibiotic susceptibility pattern but not with the isolated time course or the patients’ ward. We would like to emphasize the study limitations. First, the number of isolated bacteria in CAUTI varied in each year. Results may be affected by the number of CAUTI or by the physicians’ discretion. Second, we lacked information on patients’ clinical backgrounds. Third, this study has the retrospective nature. Fourth, the represented data were comparatively older, but we will continue this kind of study for update. These limitations including lack of patients’ background information will be overcome in our future studies. In conclusion, our findings demonstrate that E coli was the most common bacteria found among ESBL-producing bacteria in CAUTI of neurogenic bladder patients and that they could be discriminated by typing with rep-PCR using the Diversilab system. References 1. Milan PB, Ivan IM. Catheter-associated and nosocomial urinary tract infections: antibiotic resistance and influence on commonly used antimicrobial therapy. Int Urol Nephrol 2009;41:461-4.
e31
2. Bi XC, Zhang B, Ye YK, He HC, Han ZD, Dai QS, et al. Pathogen incidence and antibiotic resistance patterns of catheter-associated urinary tract infection in children. J Chemother 2009;21:661-5. 3. Yamamichi F, Shigemura K, Matsumoto M, Nakano Y, Tanaka K, Arakawa S, et al. Relationship between urinary tract infection categorization and pathogens’ antimicrobial susceptibilities. Urol Int 2012;88:198-208. 4. Kariuki S, Revathi G, Corkill J, Kiiru J, Mwituria J, Mirza N, et al. Escherichia coli from community-acquired urinary tract infections resistant to fluoroquinolones and extended-spectrum b-lactams. Infect Dev Ctries 2007;1:257-62. 5. Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005;22:627-39. 6. Wagenlehner FM, Vahlensieck W, Bauer HW, Weidner W, Piechota HJ, Naber KG. Prevention of recurrent urinary tract infections. Minerva Urol Nefrol 2013;65:9-20. 7. Church DL, Chow BL, Lloyd T, Gregson DB. Comparison of automated repetitivesequence-based polymerase chain reaction and spa typing versus pulsed-field gel electrophoresis for molecular typing of methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2011;69:30-7. 8. Hirvonen JJ, Pasanen T, Tissari P, Salmenlinna S, Vuopio J, Kaukoranta SS. Outbreak analysis and typing of MRSA isolates by automated repetitivesequence-based PCR in a region with multiple strain types causing epidemics. Eur J Clin Microbiol Infect Dis 2012;31:2935-42. 9. Ross TL, Merz WG, Farkos M, Carroll KC. Comparison of an automated repetitive sequence-based PCR microbial typing system to pulsed-field gel electrophoresis for analysis of outbreaks of methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2005;43:5642-7. 10. Deplano A, Denis O, Rodriguez-Villalobos H, De Ryck R, Struelens MJ, Hallin M. Controlled performance evaluation of the DiversiLab repetitive-sequencebased genotyping system for typing multidrug-resistant health careassociated bacterial pathogens. J Clin Microbiol 2011;49:3616-20. 11. Clinical and Laboratory Standards Institute. Performance standards for antimicrobials susceptibility testing; nineteenth Informational supplement 2009. M100-S19. Wayne [PA]: Clinical and Laboratory Standards Institute; 2009. 12. Ho PL, Chow KH, Yuen KY, Ng WS, Chan PY. Comparison of a novel, inhibitorpotentiated disc-diffusion test with other methods for the detection of extended-spectrum b-lactamases in Escherichia coli and Klebsiella pneumoniae. J Antimicrob Chemother 1998;42:49-54. 13. Buckley B, Grant AM. What is the most effective management of neurogenic bladder dysfunction? BMJ 2009;338:b659. 14. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008;77:643-50. 15. Ko YH, Kim JW, Kang SG, Jang HA, Kang SH, Park HS, et al. The efficacy of inand-out catheterization as a way of trial without catheterization strategy for treatment of acute urinary retention induced by benign prostate hyperplasia: variables predicting success outcome. Neurourol Urodyn 2012;31:460-4. 16. Niveditha S, Pramodhini S, Umadevi S, Kumar S, Stephen S. The isolation and the biofilm formation of uropathogens in the patients with catheter-associated urinary tract infections (UTIs). J Clin Diagn Res 2012;6:1478-82. 17. Tinelli M, Cataldo MA, Mantengoli E, Cadeddu C, Cunietti E, Luzzaro F, et al. Epidemiology and genetic characteristics of extended-spectrum b-lactamaseproducing gram-negative bacteria causing urinary tract infections in long-term care facilities. J Antimicrob Chemother 2012;67:2982-7. 18. Nicolas-Chanoine MH, Jarlier V. Extended-spectrum b-lactamases in longterm-care facilities. Clin Microbiol Infect 2008;14:S111-6. 19. Trindade PA, McCulloch JA, Oliveira GA, Mamizuka EM. Molecular techniques for MRSA typing: current issues and perspectives. Braz J Infect Dis 2003;7:32-43. 20. de Cueto M, Hernández JR, López-Cerero L, Morillo C, Pascual A. Activity of osfomycin against extended-spectrum b-lactamase producing Escherichia coli and Klebsiella pneumoniae. Enferm Infecc Microbiol Clin 2006;24:613-6.