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Infecc Microbiol Clin. 2019;37:656-60" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1134 "formatos" => array:2 [ "HTML" => 814 "PDF" => 320 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Profilaxis preexposición al VIH en España: situación política y administrativa" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "656" "paginaFinal" => "660" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "HIV pre-exposure prophylaxis (PrEP) in Spain: political and administrative situation" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Miguel 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=> "S300" "fechaPublicacion" => "2019-12-01" "aid" => "1995" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Enferm Infecc Microbiol Clin. 2019;37:648-51" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 370 "formatos" => array:2 [ "HTML" => 238 "PDF" => 132 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Detection of carbapenemase-producing <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>: Evaluation of the carbapenem inactivation method (CIM)" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "648" "paginaFinal" => "651" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Detección de <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> productoras de carbapenemasas: evaluación del método de inactivación de carbapenem" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1008 "Ancho" => 2085 "Tamanyo" => 106382 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of carbapenem inactivation method (CIM) zone diameter measurements. Displayed are the number of CIM readings with specific zone diameter measurements during the study. A total of 266 isolates were tested, 171 were carbapenemases-producers and 95 were non-carbapenemases producers. (A) Zone diameter measures representing the data obtained using imipenem disk as substrate in the CIM; (B) zone diameter measures representing the data obtained using meropenem disk as substrate in the CIM.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sergio Gutiérrez, Adriana Correa, Cristhian Hernández-Gómez, Elsa De La Cadena, Christian Pallares, María Virginia Villegas" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Sergio" "apellidos" => "Gutiérrez" ] 1 => array:2 [ "nombre" => "Adriana" "apellidos" => "Correa" ] 2 => array:2 [ "nombre" => "Cristhian" "apellidos" => "Hernández-Gómez" ] 3 => array:2 [ "nombre" => "Elsa" "apellidos" => "De La Cadena" ] 4 => array:2 [ "nombre" => "Christian" "apellidos" => "Pallares" ] 5 => array:2 [ "nombre" => "María Virginia" "apellidos" => "Villegas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X1930231X" "doi" => "10.1016/j.eimce.2019.09.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X1930231X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X19301272?idApp=UINPBA00004N" "url" => "/0213005X/0000003700000010/v1_201911290911/S0213005X19301272/v1_201911290911/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "ESBL-producing-multidrug resistant <span class="elsevierStyleItalic">E. coli</span> population from urinary tract infections is less diverse than non-ESBL-multidrug resistant population" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "652" "paginaFinal" => "655" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "David M. Arana, Aída Sánchez, Verónica Bautista, Jesús Oteo-Iglesias, Juan-Ignacio Alós" "autores" => array:5 [ 0 => array:3 [ "nombre" => "David M." "apellidos" => "Arana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Aída" "apellidos" => "Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Verónica" "apellidos" => "Bautista" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Jesús" "apellidos" => "Oteo-Iglesias" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:4 [ "nombre" => "Juan-Ignacio" "apellidos" => "Alós" "email" => array:1 [ 0 => "nachoalos@telefonica.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Getafe, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Microbiología, Laboratorio Clínico General BR Salud, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratorio de Referencia e Investigación en Resistencia a Antibióticos, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La población de <span class="elsevierStyleItalic">E. coli</span> multirresistente productora de BLEE presente en infecciones del tracto urinario es menos diversa que la población multirresistente no productora de BLEE" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1206 "Ancho" => 3079 "Tamanyo" => 326344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dendrograms illustrating the PFGE profiles of 33 non-ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates (a) and 33 ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates (b).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urinary tract infections (UTIs) are highly prevalent worldwide and represent a clinical problem in both, community and hospital settings. Empirical therapy has been effective for years because susceptibility profiles among Gram-negative uropathogens have been relatively stable over the time. However, the emergence of multidrug resistance (MDR) has radically changed the situation with the emergence and dissemination of strains harboring extended-spectrum β-lactamases (ESBL) and less frequently class C β-lactamases and carbapenemases.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> MDR is often associated with worldwide-disseminated high-risk clones such as <span class="elsevierStyleItalic">E. coli</span> sequence type (ST) 131, which is considered a high-risk <span class="elsevierStyleItalic">E. c</span> clone mostly associated with UTI and bacteraemia.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The dissemination of ESBL-producing <span class="elsevierStyleItalic">E. coli</span> has been extensively reported,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> however only a few studies, in different countries and human populations, have specifically studied the heterogeneity in population structure among susceptible, resistant and resistant by ESBL producing <span class="elsevierStyleItalic">E. coli</span>.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This study aims to compare the population structure of three different representative groups of <span class="elsevierStyleItalic">E. coli</span> isolates causing UTI and also to evaluate alternative antimicrobial agents in each MDR group.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Prospective collection of MDR and susceptible <span class="elsevierStyleItalic">E. coli</span> isolates.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Strains of <span class="elsevierStyleItalic">E. coli</span> isolated from patients with urinary tract infection were collected between March and April 2017 in order to form three different groups: non ESBL-MDR, ESBL-MDR and a group susceptible to all the antibiotics. The samples were collected from 6 different medical areas representative of Madrid and responsible for the care of around 1,460,000 inhabitants.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this study, MDR was defined as resistance at least to amoxicillin, ciprofloxacin, gentamicin and trimethoprim sulfamethoxazole according to their clinical MIC breakpoints.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> Suspected ESBL-producing isolates were phenotypically characterized using double-disk synergy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Bacterial identification and antimicrobial susceptibility testing</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bacterial identification was performed by MALDI-TOF MS (Bruker Daltonik GmbH, Leipzig, Germany). Antibiotic susceptibility testing was performed by broth microdilution (MicroScan, Beckman Coulter, Inc; Brea, California) and interpreted according to the European Committee for Antimicrobial Susceptibility Testing (EUCAST) breakpoints.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Susceptibility to ceftolozane/tazobactam was tested by E-test (Liofilchem, Roseto degli Abruzzi, Italy) at a fixed concentration of tazobactam of 4<span class="elsevierStyleHsp" style=""></span>mg/L.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A chi square test (<a href="http://www.socscistatistics.com/tests/chisquare/">http://www.socscistatistics.com/tests/chisquare/</a>) was applied to analyze differences in susceptibility to alternative antibiotics among non ESBL and ESBL groups. A <span class="elsevierStyleItalic">p</span>-value <0.05 was considered as statistically significant.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Molecular characterization of ESBL</span><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of genes encoding ESBL (<span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">SHV</span>, <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M</span> and <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">TEM</span>) was determined by using PCR and sequencing.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Population structure analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Epidemiological relatedness was studied by PFGE of <span class="elsevierStyleItalic">Xba</span>I-digested DNA.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MLST was performed on randomly selected representative isolates from each clonal type (<a href="https://enterobase.warwick.ac.uk/species/ecoli/allele_st_search">https://enterobase.warwick.ac.uk/species/ecoli/allele_st_search</a>).</p><p id="par0060" class="elsevierStylePara elsevierViewall">A Simple Diversity Index (SDI) was calculated in order to quantify the genetic variability in each group. The index was calculated as the total number of different PFGE profiles of each group/total number of strains in each group<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Antimicrobial susceptibility to alternative antibiotics</span><p id="par0065" class="elsevierStylePara elsevierViewall">Antimicrobial susceptibility results are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. No statistically significant differences between both MDR groups were observed.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Only 2 isolates from the ESBL MDR group were resistant to ceftolozane/tazobactam (MIC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg/L and MIC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mg/L) while all the non-ESBL MDR strains were susceptible. A slight but non-significant increase in MIC was observed in the ESBL MDR group respect to the non-ESBL MDR group (MIC 50: 0.5<span class="elsevierStyleHsp" style=""></span>mg/L and 0.38<span class="elsevierStyleHsp" style=""></span>mg/L, respectively; MIC 90: 1<span class="elsevierStyleHsp" style=""></span>mg/L and 0.5<span class="elsevierStyleHsp" style=""></span>mg/L, respectively).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Molecular characterization of ESBL and molecular typing</span><p id="par0075" class="elsevierStylePara elsevierViewall">All of the suspected ESBL-producing MDR strains were confirmed by PCR and sequencing. 71.4% produced CTX-M-15; 8.6% produced CTX-M-14; 8.6% produced SHV-12, 2.8% produced CTX-M-65; 2.8% produced CTX-M-27 and 5.7% co-produced both CTX-M-15 and CTX-M-14.</p><p id="par0080" class="elsevierStylePara elsevierViewall">PFGE analysis revealed a high degree of genetic diversity in susceptible and non ESBL-MDR groups. Thirty-three strains from the non ESBL-MDR group were analyzed by PFGE and 30 different patterns were observed (SDI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>90.9) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). However, the ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> population was less diverse and 24 different patterns were observed (SDI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>72.7) respect to 33 strains analyzed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). Two defined clusters: C1 (6 isolates) and C2 (4 isolates), consisting of CTX-M-15 producing isolates, were detected with a genetic linkage 83%. Representative isolates from each cluster were analyzed by MLST and all of them belonged to ST131 complex. The CTX-M-14 producing isolates belonged to ST23 complex. No PFGE patterns were obtained from two of the three SHV-12 producing isolates detected, but 2 of them studied by MLST belonged to CC350. The CTX-M-27 producing isolate belonged to ST1193 (ST14 complex). Three PFGE clusters were detected in the non ESBL-MDR group (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a); by MLST these clusters belonged to ST131, ST744 and ST23. All the isolates from the susceptible group were different (SDI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100) and no clonal association was detected (data not shown).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">All the ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates resistant to piperacillin/tazobactam (11.4%), fosfomycin (14.3%) and ceftolozane/tazobactam (5.7%) produced CTX-M-15.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Eighty percent of fosfomycin resistant isolates and only 25% of piperacillin/tazobactam resistant isolates grouped in the ST131-CTX-M-15-producing-MDR <span class="elsevierStyleItalic">E. coli</span> cluster (C1 and C2). The two isolates resistant to ceftolozane/tazobactam were not clonally related.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">MDR in urine isolates is often associated with the presence of ESBL genes, as well as aminoglycoside and quinolone resistance.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> Previous studies have reported that the emergence and spread of different high-risk clones, such as <span class="elsevierStyleItalic">E. coli</span> ST131 or <span class="elsevierStyleItalic">K. pneumoniae</span> ST258, have been largely responsible for the sudden increase in MDR.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> Specifically, a recent study in Spain has addressed the prevalence and dynamics of <span class="elsevierStyleItalic">E. coli</span> ST131 among contacts of infected patients.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> As a starting point, our group reported a recent local retrospective study in which it was analyzed the evolution of multidrug resistance (using the same MDR markers) in urine samples from both, outpatients and inpatients, over a 12-year period. This study showed that MDR is a phenomenon that is increasing not only in hospitalized, but also at a community level.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> Following with the same idea, the present study was designed to take a new step in this direction and describe the diversity in population structure between susceptible, MDR (non-ESBL) and MDR-ESBL producing <span class="elsevierStyleItalic">E. coli</span> irrespective of the origin (community acquired- or hospital acquired UTI). The PFGE analysis showed that there was a great clonal diversity among isolates in non ESBL-MDR group with smaller clusters while the ESBL-MDR group was rather less diverse and more clonal. Almost half of the ESBL-MDR isolates (14 isolates, 40%) were grouped in a large cluster and all of them belonged to a ST131 complex (inferred by the MLST results obtained) and produced CTX-M-15 beta-lactamase. The MDR strains selected in this study are representative of a significant human population in a country with a high consumption of antibiotics,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> and corroborate previous studies in which the ESBL population in non-hospitalized patients was less diverse and was dominated mostly by ST131.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Other studies have reported similar results in samples from a different origin such as bloodstream infections <a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5,13</span></a> or according the patient characteristics.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The predominance of the MDR ST131 clone as a cause of UTIs and bacteraemia represents a challenge for the treatment of these infections. Recent studies have demonstrated that β-lactam/β-lactamase-inhibitor combinations are suitable alternatives to carbapenems for treating patients with UTI or bloodstream infections due to ESBL-producing <span class="elsevierStyleItalic">E. coli</span>.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">15,16</span></a> We found a high rate of <span class="elsevierStyleItalic">in vitro</span> susceptibility to piperacillin/tazobactam among MDR ESBL-producing isolates (88.6%). Only four isolates were resistant to piperacillin/tazobactam among MDR ESBL-producing isolates, three of which were susceptible to ceftolozane/tazobactam. In total, 33 of 35 MDR ESBL-producing isolates (94.3%) were susceptible to ceftolozane/tazobactam. These findings are in line with previous studies carried out at different countries in which ceftolozane/tazobactam has demonstrated excellent overall <span class="elsevierStyleItalic">in vitro</span> activity against the vast majority of <span class="elsevierStyleItalic">E. coli</span> isolates including ESBL-phenotype and MDR strains.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">It should be also taken into account the percentage of susceptibility to antibiotics considered as the first line for empirical treatment of acute uncomplicated cystitis such as fosfomycin and nitrofurantoin. We found higher rates of resistance, but not significant, to fosfomycin among MDR ESBL-producing isolates (14.3%) with respect to the MDR non-ESBL isolates (5.7%), result that is in accordance with other studies in which the presence of ESBL entails a higher resistance to fosfomycin.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The strength of the report is that the study was carried out in urine samples taken from 6 different medical areas which are responsible for the care of around 1,460,000 inhabitants (25 per cent of the Autonomous Community of Madrid population) and therefore, representative of a large area of Madrid. However, the study has also some limitations; the relatively small number of isolates characterized and the lack of detailed information about the patient characteristics.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Overall, these findings suggest that ST131 dominate the ESBL-producing lineages in the MDR uropathogenic <span class="elsevierStyleItalic">E. coli</span> in a representative area of Madrid. Therefore, molecular epidemiology and clonal group surveillance studies are necessary to evaluate the evolution over the time of MDR high-risk clones due to their capability to disseminate and to acquire more antimicrobial resistant determinants.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical approval</span><p id="par0120" class="elsevierStylePara elsevierViewall">Not required.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">D.M.A has received a research grant from the Investigator Initiated Studies Program economically supported by <span class="elsevierStyleGrantSponsor" id="gs1">Merck Sharp and Dohme</span> (MSD).</p><p id="par0130" class="elsevierStylePara elsevierViewall">This work was also supported by Plan Nacional de I+D+i 2013–2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Economía, Industria y Competitividad, Spanish Network for Research in Infectious Diseases (REIPI RD16CIII/0004/0002) – co-financed by European Development Regional Fund <span class="elsevierStyleGrantSponsor" id="gs2">ERDF</span> “A way to achieve Europe”, Operative program Intelligent Growth 2014–2020.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1269790" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1175285" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1269789" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1175284" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Prospective collection of MDR and susceptible E. coli isolates." ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Bacterial identification and antimicrobial susceptibility testing" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Molecular characterization of ESBL" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Population structure analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Antimicrobial susceptibility to alternative antibiotics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Molecular characterization of ESBL and molecular typing" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Ethical approval" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-12-06" "fechaAceptado" => "2019-02-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1175285" "palabras" => array:4 [ 0 => "Multidrug resistance" 1 => "Population structure" 2 => "ESBL" 3 => "UTI" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1175284" "palabras" => array:4 [ 0 => "Multirresistencia" 1 => "Estructura poblacional" 2 => "BLEE" 3 => "ITU" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to compare the population structure of three different representative groups of <span class="elsevierStyleItalic">E. coli</span> isolates causing urinary tract infections in a large area of Madrid, Spain: two groups of multidrug resistant isolates (MDR), ESBL- and non-ESBL producers, and one of fully-susceptible isolates (35 isolates in each group).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Epidemiological relatedness was studied by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). The presence of genes encoding ESBL was determined by using PCR and sequencing. Antimicrobial susceptibility testing was performed by broth microdilution.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">PFGE analysis revealed a high degree of genetic diversity in susceptible and non-ESBL-MDR groups. However, the ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> population was less diverse and a large cluster consisting of ST131 and CTX-M-15-producing isolates was detected.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The present study revealed that ESBL-producing-MDR <span class="elsevierStyleItalic">E. coli</span> population was less diverse than the non-ESBL MDR group and that ST131 was dominant among CTX-M-15-producing isolates that reflects the spread of this successful MDR lineage.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente estudio fue comparar la estructura poblacional de tres grupos representativos diferentes de aislados de <span class="elsevierStyleItalic">E. coli</span> que producen infecciones del tracto urinario en una gran área de Madrid, España: dos grupos de aislados multirresistentes (<span class="elsevierStyleItalic">multidrug resistant</span>, MDR), productores y no productores de BLEE (β-lactamasas de espectro extendido), y uno de aislados totalmente sensibles (35 aislamientos en cada grupo).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La relación epidemiológica se estudió mediante electroforesis en gel de campo pulsado (<span class="elsevierStyleItalic">pulsed-field gel electrophoresis</span>, PFGE) y tipificación de secuencias multilocus (<span class="elsevierStyleItalic">multilocus sequence typing</span>, MLST). La presencia de genes que codifican para BLEE se determinó mediante el uso de PCR y secuenciación. La prueba de sensibilidad a los antimicrobianos se realizó por microdilución del medio.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El análisis de PFGE reveló un alto grado de diversidad genética en el grupo de sensibles y de MDR no productores de BLEE. Sin embargo, la población de <span class="elsevierStyleItalic">E. coli</span> MDR productora de BLEE era menos diversa y se detectó un grupo grande de aislados formado por productores de CTX-M-15 y ST131.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El presente estudio reveló que la población de <span class="elsevierStyleItalic">E. coli</span> MDR productora de BLEE era menos diversa que el grupo MDR no productor de BLEE, y que ST131 era dominante en los aislados de productores de CTX-M-15, lo que refleja la propagación de esta exitosa línea de MDR.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1206 "Ancho" => 3079 "Tamanyo" => 326344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dendrograms illustrating the PFGE profiles of 33 non-ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates (a) and 33 ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates (b).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">NA: not applicable.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Antibiotics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-ESBL MDR</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESBL-MDR</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><span class="elsevierStyleItalic">p</span>-value (<0.05) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MIC90<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Susceptibility (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MIC90<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Susceptibility (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fosfomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nitrofurantoin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Piperacillin/tazobactam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amoxicillin/clavulanate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceftolozane/tazobactam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ertapenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Imipenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meropenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amikacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2172136.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">MICs in mg/L.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Antibiotic susceptibility of non-ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates and ESBL-MDR <span class="elsevierStyleItalic">E. coli</span> isolates.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The emerging threat of multidrug-resistant Gram-negative bacteria in urology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.M. 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Brief report
ESBL-producing-multidrug resistant E. coli population from urinary tract infections is less diverse than non-ESBL-multidrug resistant population
La población de E. coli multirresistente productora de BLEE presente en infecciones del tracto urinario es menos diversa que la población multirresistente no productora de BLEE
David M. Aranaa, Aída Sánchezb, Verónica Bautistac,d, Jesús Oteo-Iglesiasc,d, Juan-Ignacio Alósa,
Autor para correspondencia
a Servicio de Microbiología, Hospital Universitario Getafe, Madrid, Spain
b Servicio Microbiología, Laboratorio Clínico General BR Salud, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
c Laboratorio de Referencia e Investigación en Resistencia a Antibióticos, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
d Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain