Phylogenetic groups and antimicrobial susceptibility patterns of uropathogenic Escherichia coli clinical isolates from patients at Mulago National Referral Hospital, Kampala, Uganda

Introduction: Uropathogenic Escherichia coli (UPEC) remains the most common cause of urinary tract infections (UTIs). They account for over 80-90% of all community-acquired and 30-50% of all hospital-acquired UTIs. E. coli strains have been found to belong to evolutionary origins known as phylogenetic groups. In 2013, Clermont classified E. coli strains into eight phylogenetic groups using the quadruplex PCR method. The aim of this study was to identify the phylogenetic groups of UPEC strains in Uganda using Clermont’s quadruplex PCR method and to assess their antibiotic susceptibility patterns in Uganda. Methods: In this cross-sectional study, 140 stored uropathogenic E. coli isolates from the Clinical Microbiology Laboratory, Department of Medical Microbiology, College of Health Sciences Makerere University were subjected to phylogenetic typing by a quadruplex PCR method. Antimicrobial susceptibility testing was performed by disk diffusion method according to Clinical & Laboratory Standards Institute (CLSI) guidelines. Phenotypic detection of extended-spectrum beta-lactamase, AmpC and carbapenemases was done according to CLSI guidelines and Laboratory SOPs. Results: Phylogenetic group B2 (40%) was the most predominant, followed by A (6.23%), clade I and II (5%), D and E (each 2.14%), B1 (1.43%) and F and C (each 0.71%). The most common resistant antibiotic was trimethoprim-sulphamethoxazole (90.71%) and the least was imipenem (1.43%). In total, 73.57% of isolates were multi-drug resistant (MDR). Antibiotic resistance was mainly detected in phylogenetic group B2 (54%). Conclusions: Our findings showed the high prevalence of MDR E. coli isolates, with the dominance of phylogenetic group B2. About 9% of E. coli isolates belonged to the newly described phylogroups C, E, F, and clade I and II.

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Detection of Phylogenetic Groups and Drug Resistance Genes of Escherichia coli Causing Urinary Tract Infection in Southwest Iran

Jundishapur Journal of Microbiology ◽

10.5812/jjm.112547 ◽

2021 ◽

Vol 14 (2) ◽

Author(s):

Mostafa Boroumand Boroumand ◽

Mohsen Naghmachi ◽

Mohammad Amin Ghatee

Keyword(s):

Escherichia Coli ◽

Antibiotic Resistance ◽

Urinary Tract ◽

Resistance Genes ◽

Antibiotic Resistance Genes ◽

Phylogenetic Group ◽

Phylogenetic Groups ◽

E Coli ◽

Pcr Method ◽

Tract Infections

Background: Many bacteria can cause urinary tract infections (UTIs), among which Escherichia coli is the most common causative agent. E. coli strains are divided into eight phylogenetic groups based on the new Quadroplex-PCR method, which are different in terms of patterns of resistance to antibiotics, virulence, and environmental characteristics. Objectives: This study aimed to determine the phylogenetic groups and the prevalence of drug resistance genes in E. coli strains causing UTIs. Methods: In this descriptive cross-sectional study, 129 E. coli isolates obtained from the culture of patients with UTIs were evaluated for phylogenetic groups using the new method of Clermont et al. The identification of phylogenetic groups and antibiotic resistance genes was performed using the multiplex polymerase chain reaction (PCR) method. Results: In this study, concerning the distribution of phylogenetic groups among E. coli isolates, the phylogenetic group B2 (36.4%) was the most common phylogenetic group, followed by phylogroups C (13.2%), clade I (10.1%), D (9.3%), and A (3.1%) while groups B1 and F were not observed in any of the isolates, and 20.2% had an unknown state. Also, out of 129 E. coli isolates, the total frequency of tetA, tetB, sul1, sul2, CITM, DfrA, and qnr resistance genes was 59.7%, 66.7, 69, 62, 30.2, 23.3, and 20.2%, respectively. In this study, there was a significant relationship between antibiotics (P = 0.026), cefotaxime (P = 0.003), and nalidixic acid (P = 0.044) and E. coli phylogenetic groups. No significant relationship was observed between E. coli phylogenetic groups and antibiotic resistance genes. Conclusions: The results of this study showed that strains belonging to group B2 had the highest prevalence among other phylogroups, and also, the frequency of antibiotic resistance genes and drug-resistant isolates had a higher prevalence in this phylogroup. These results show that phylogroup B2 has a more effective role in causing urinary tract infections compared to other phylogroups, and this phylogroup can be considered a genetic reservoir of antibiotic resistance.

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Detection of virulence genes, phylogenetic group and antibiotic resistance of uropathogenic Escherichia coli in Mongolia

The Journal of Infection in Developing Countries ◽

10.3855/jidc.7903 ◽

2017 ◽

Vol 11 (01) ◽

pp. 51-57 ◽

Cited By ~ 17

Author(s):

Yandag Munkhdelger ◽

Nyamaa Gunregjav ◽

Altantsetseg Dorjpurev ◽

Nishi Juniichiro ◽

Jav Sarantuya

Keyword(s):

Escherichia Coli ◽

Antibiotic Resistance ◽

Virulence Genes ◽

Wide Spectrum ◽

Iron Acquisition ◽

Uropathogenic Escherichia Coli ◽

Phylogenetic Group ◽

Diffusion Method ◽

Phylogenetic Groups ◽

E Coli

Introduction: The severity of urinary tract infection (UTI) produced by uropathogenic Escherichia coli (UPEC) is due to the expression of a wide spectrum of virulence genes. E. coli strains were divided into four phylogenetic groups (A, B1, B2 and D) based on their virulence genes. The present study aimed to assess the relationship between virulence genes, phylogenetic groups, and antibiotic resistance of UPEC. Methodology: A total of 148 E. coli were tested for antimicrobial resistance against 10 drugs using the disk diffusion method. The isolates were screened by polymerase chain reaction (PCR) for detection of virulence genes and categorized into the four major phylogenetic groups. Results: Phylogenetic group B2 was predominant (33.8%), followed by D (28.4%), A (19.6), and B1 (18.2%). A higher prevalence of fimH (89.9%), fyuA (70.3%), traT (66.2%), iutA (62.2%), kpsMTII (58.8%), and aer (56.1%) genes were found in UPEC, indicating a putative role of adhesins, iron acquisition systems, and protectins that are main cause of UTIs. The most common antibiotic resistance was to cephalotin (85.1%), ampicillin (78.4%) and the least to nitrofurantoin (5.4%) and imipenem (2%). In total, 93.9% of isolates were multidrug resistant (MDR). Conclusions: This study showed that group B2 and D were the predominant phylogenetic groups and virulence-associated genes were mostly distributed in these groups. The virulence genes encoding components of adhesins, iron acquisition systems, and protectins were highly prevalent among antibiotic-resistant UPEC. Although the majority of strains are MDR, nitrofurantoin is the drug of choice for treatment of UTI patients in Ulaanbaatar.

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Drug resistance, serotypes, and phylogenetic groups among uropathogenic Escherichia coli including O25-ST131 in Mexico City

The Journal of Infection in Developing Countries ◽

10.3855/jidc.1703 ◽

2011 ◽

Vol 5 (12) ◽

pp. 840-849 ◽

Cited By ~ 36

Author(s):

José Molina-López ◽

Gerardo Aparicio-Ozores ◽

Rosa María Ribas-Aparicio ◽

Sandra Gavilanes-Parra ◽

María Elena Chávez-Berrocal ◽

...

Keyword(s):

Escherichia Coli ◽

Multidrug Resistance ◽

Mexico City ◽

Uropathogenic Escherichia Coli ◽

Diffusion Method ◽

Phylogenetic Groups ◽

Disk Diffusion Method ◽

E Coli ◽

Pcr Multiplex ◽

Tract Infections

Introduction: The increasing prevalence of uropathogenic Escherichia coli (UPEC) strains resistant to multiple antibiotics complicates the treatment of urinary tract infections (UTIs). This study aimed to analyze the antimicrobial resistance, serotypes, and phylogenetic groups among strains of E. coli isolated from outpatients with UTIs in Mexico City. Methodology: A total of 119 E. coli isolates were recovered from urine samples from outpatients with clinical diagnosis of uncomplicated UTIs from 2004 to 2007. The serotype was assessed by agglutination in microtiter plates; susceptibility to antimicrobials was determined by the disk diffusion method. Clone O25-ST131 and phylogenetic groups of E. coli strains were tested by methods based on PCR multiplex. Results: The predominant serotype was O25:H4 (21.2%). Resistance to antibiotics was ampicillin (83.7%); piperacillin (53.8%); the fluoroquinolone group (55.5-60.6%), and trimethoprim/sulfamethoxazole (TMP/SMX) (56.4%). Additionally, 36 (30.2%) isolates were multidrug-resistant and 13 of these 36 strains were identified as E. coli O25-ST131 clone by an allele-specific PCR-based assay. Phylogenetic analysis showed that 15 of 17 isolates with serotype O25:H4 belonged to group B2. Conclusions: This is the first report that establishes the presence in Mexico of the O25-ST131 clonal group of E. coli, which has been associated with multidrug-resistance and with high virulence potential. The spread of this clone in Mexico should be monitored closely. We found a correlation between serotype O25:H4 and multidrug resistance in UPEC strains. Our results indicate that the use of ampicillin, fluoroquinolones, and TMP/SMX should be reviewed when selecting empirical therapy for UTIs.

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Phylogenetic Groups and Antimicrobial Susceptibility Patterns of Escherichia coli from Healthy Chicken in Eastern and Central Uganda

Journal of Veterinary Medicine ◽

10.1155/2018/9126467 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6 ◽

Cited By ~ 6

Author(s):

Winston Kabiswa ◽

Ann Nanteza ◽

Gabriel Tumwine ◽

Samuel Majalija

Keyword(s):

Antimicrobial Resistance ◽

Phylogenetic Group ◽

Diffusion Method ◽

Eastern Region ◽

Phylogenetic Groups ◽

Antimicrobial Drugs ◽

E Coli ◽

Group A ◽

Eastern Uganda ◽

Susceptibility Patterns

Antimicrobial resistance is an emerging problem in both humans and animals due to misuse and excessive use of drugs. Resistance in commensal E. coli isolates can be used to predict emergence of resistance in other gut microflora. The aim of this study is to determine the phylogenetic groups and antimicrobial resistance patterns of E. coli from healthy chickens in Uganda. The phylogenetic grouping of 120 fecal E. coli isolates from eastern and central Uganda was derived using the triplex PCR assay and their susceptibility patterns determined by agar disc diffusion method to 5 antimicrobial drugs. Most E. coli is segregated into phylogenetic group A comprising 84%, while 12% and 4% were in groups D and B1, respectively. Similarly most E. coli from central (87%) and eastern Uganda (82%) belonged to group A. Overall, 85 (70%) of E. coli were resistant to antimicrobial drugs, of which 72/101 (70%) are in PG A, 10 of 14 (71.4%) in PG D, and 3 of 5 (60%) in PG B1. Significantly, most of the isolates in PG A from both central (66.7%) and (60.6%) eastern Uganda were resistant to one antimicrobial. Resistance to tetracycline alone or in combination with other drugs for central and eastern Uganda in PG A is 51% and 55%, respectively. Multidrug resistance to tetracycline and ciprofloxacin or nalidixic acid was 10% and 18% in isolates from central and 10% and 12% in isolates from eastern region, respectively. Phylogenetic group A accounts for most of the E. coli in chicken from Uganda. No difference in the resistance rates between the phylogenetic groups of E. coli has been observed. The high prevalence of resistant E. coli strains from different phylogenetic groups in healthy chickens suggests antimicrobial drug selection pressure due to excessive drug in the rearing layer chickens.

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Determination of the frequency of β-lactamase genes (bla SHV, bla TEM, bla CTX-M) and phylogenetic groups among ESBL-producing uropathogenic Escherichia coli isolated from outpatients

Journal of Laboratory Medicine ◽

10.1515/labmed-2018-0136 ◽

2020 ◽

Vol 44 (1) ◽

pp. 27-33 ◽

Cited By ~ 1

Author(s):

Shiva Mirkalantari ◽

Faramarz Masjedian ◽

Gholamreza Irajian ◽

Emmanuel Edwar Siddig ◽

Azam Fattahi

Keyword(s):

Escherichia Coli ◽

Resistance Pattern ◽

Phylogenetic Groups ◽

Accurate Identification ◽

E Coli ◽

Resistance Patterns ◽

Phylogenetic Grouping ◽

Pcr Method ◽

Tract Infections

Abstract Background Escherichia coli accounts for 70–95% of community-acquired urinary tract infections (UTIs). Recently, there has been an increase in the prevalence of extended-spectrum β-lactamase (ESBL) in the community which required an accurate identification for better management. Therefore, the current study was performed to determine the antimicrobial resistance pattern, investigate ESBL phenotypes and genotypes (blaCTX-M, bla TEM and bla SHV genes) and determine the phylogenetic groups among ESBL-positive isolates from outpatients. Methods One hundred and eighty-three positive urine samples were collected from 4450 outpatient clinic attendees. Antibiotic susceptibility was determined and ESBL phenotype screening was carried out using disk diffusion agar and combination disk techniques, respectively. The assessment of the presence of the blaCTX-M, bla TEM and blaSHV genes and phylogenetic grouping were performed using the polymerase chain reaction (PCR) method. Results Out of 183 E. coli isolates, 59 (32.2%) showed a positive ESBL phenotype. The prevalence of ESBL-producing E. coli was higher in males (57.4%). Fifty-seven of the ESBL-producing strains carried at least one of the β-lactamase genes (bla CTX-M, bla TEM, bla SHV). Phylotyping of multi-drug resistant isolates indicated that the isolates belonged to B2, A and D phylogroups. Analysis of resistance patterns among these phylogroups revealed that 74.4%, 55.3% and 29.7% of the isolates in the B2 group were resistant to trimethoprim-sulfamethoxazole, ciprofloxacin and gentamicin, respectively. Most of the strains in the phylogroup B2 carried the bla CTX-M gene. Conclusions All the ESBL-producing isolates were placed in one of the four phylogenetic groups. The presence of CTX-M and resistance to quinolones were more frequent in B2 strains than in non-B2 strains.

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Characterization of multidrug-resistant Escherichia coli isolated from extraintestinal clinical infections in animals

Journal of Medical Microbiology ◽

10.1099/jmm.0.018002-0 ◽

2010 ◽

Vol 59 (5) ◽

pp. 592-598 ◽

Cited By ~ 19

Author(s):

Justine S. Gibson ◽

Rowland N. Cobbold ◽

Darren J. Trott

Keyword(s):

Escherichia Coli ◽

Antimicrobial Susceptibility ◽

Animal Species ◽

Antimicrobial Agents ◽

Multidrug Resistant ◽

Phylogenetic Group ◽

Phylogenetic Groups ◽

Diagnostic Laboratory ◽

E Coli

Multidrug-resistant (MDR) Escherichia coli causes extraintestinal infections in both humans and animals. This study aimed to determine whether MDR E. coli isolates cultured from extraintestinal infections in several animal species were clonal and crossed host-species boundaries, as suggested by initial characterization of a subset of canine and human isolates, or whether they represented a diverse group of host-specific strains. Isolates were obtained either from The University of Queensland Veterinary Diagnostic Laboratory or from an independent diagnostic laboratory between October 1999 and December 2007. Ninety-six MDR E. coli isolates cultured from extraintestinal clinical infections in 55 animals comprising dogs (n=45), cats (n=5), horses (n=4) and a koala (n=1) were analysed by phylogenetic grouping, antimicrobial susceptibility testing and PFGE. The isolates were cultured from the urinary tract (n=61), reproductive tract (n=11), wounds (n=11), surgical site infections (n=4) and other sites (n=9). Isolates from the same E. coli phylogenetic group with 100 % PFGE similarity and the same antimicrobial susceptibility pattern were considered to be repeat clones and excluded from further analysis. Three of the four E. coli phylogenetic groups (A, n=19; B1, n=8; and D, n=49) were represented. Analysis of PFGE similarity identified clusters of related phylogenetic group A isolates [clonal group (CG) 1] and group D isolates (CG2 and CG3), with the remainder of the isolates demonstrating diversity. The majority of CG2 isolates contained a plasmid-borne AmpC β-lactamase, imparting resistance to cefoxitin and third-generation cephalosporins, and were obtained between 2000 and 2003. CG3 isolates were sensitive to these antimicrobial agents and appeared to replace CG2 isolates as the dominant clones from 2003 to 2007. Apart from several canine and feline isolates that demonstrated clonality, PFGE profiles tended to be divergent across species. Whilst MDR E. coli isolates from extraintestinal infections in different animal species are diverse, some dominant CGs may persist over several years.

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Carbapenem Resistance Profiles of Pathogenic Escherichia coli in Uganda

European Journal of Biology and Biotechnology ◽

10.24018/ejbio.2021.2.2.171 ◽

2021 ◽

Vol 2 (2) ◽

pp. 63-73

Author(s):

Kenneth Ssekatawa ◽

Denis K. Byarugaba ◽

Jesca L. Nakavuma ◽

Charles D. Kato ◽

Francis Ejobi ◽

...

Keyword(s):

Escherichia Coli ◽

Virulence Factors ◽

Virulence Genes ◽

Carbapenem Resistance ◽

Phylogenetic Group ◽

Clinical Isolates ◽

Phylogenetic Groups ◽

Phenotypic Resistance ◽

E Coli ◽

Tract Infections

Escherichia coli has been implicated as one of the main etiological agents of diarrhea, urinary tract infections, meningitis and septicemia worldwide. The ability to cause diseases is potentiated by presence of virulence factors. The virulence factors influence the capacity of E. coli to infect and colonize different body systems. Thus, pathogenic E. coli are grouped into DEC strains that are mainly clustered in phylogenetic group B1 and A; ExPEC belonging to A, B2 and D. Coexistence of virulence and beta-lactamase encoding genes complicates treatment outcomes. Therefore, this study aimed at presenting the carbapenem resistance (CR) profiles among pathogenic E. coli. This was a retrospective cross-sectional study involving use of 421 archived E. coli clinical isolates collected in 2019 from four Uganda tertiary hospitals. The isolates were subjected to antibiotics sensitivity assays to determine phenotypic resistance. Four sets of multiplex PCR were performed to detect CR genes, DEC pathotypes virulence genes, ExPEC PAI and the E. coli phylogenetic groups. Antibiotic susceptibility revealed that all the 421 E. coli isolates used were MDR as they exhibited 100% resistance to more than one of the first-line antibiotics. The study registered phenotypic and genotypic CR prevalence of 22.8% and 33.0% respectively. The most predominant gene was blaOXA-48 with genotypic frequency of 33.0%, then blaVIM (21.0%), blaIMP (16.5%), blaKPC (14.8%) and blaNDM (14.8%). Spearman’s correlation revealed that presence of CR genes was highly associated with phenotypic resistance. Furthermore, of 421 MDR E. coli isolates, 19.7% harboured DEC virulence genes, where EPEC recorded significantly higher prevalence (10.8%) followed by S-ETEC (3.1%), STEC (2.9%), EIEC (2.0%) and L-ETEC (2.0%). Genetic analysis characterized 46.1% of the isolates as ExPEC and only PAI IV536 (33.0%) and PAI IICFT073 (13.1%) were detected. Phylogenetic group B2 was predominantly detected (41.1%), followed by A (30.2%), B1(21.6%), and D (7.1%). Furthermore, 38.6% and 23.1% of the DEC and ExPEC respectively expressed phenotypic resistance. Our results exhibited significant level of CR carriage among the MDR DEC and ExPEC clinical isolates belonging to phylogenetic groups B1 and B2 respectively. Virulence and CR genetic factors are mainly located on mobile elements. Thus, constitutes a great threat to the healthcare system as this promotes horizontal gene transfer.

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Identification of Extended-Spectrumβ-LactamasesEscherichia coliStrains Isolated from Market Garden Products and Irrigation Water in Benin

BioMed Research International ◽

10.1155/2015/286473 ◽

2015 ◽

Vol 2015 ◽

pp. 1-11 ◽

Cited By ~ 1

Author(s):

Wassiyath Moussé ◽

Haziz Sina ◽

Farid Baba-Moussa ◽

Pacôme A. Noumavo ◽

Nadège A. Agbodjato ◽

...

Keyword(s):

Escherichia Coli ◽

Antimicrobial Susceptibility ◽

Irrigation Water ◽

Food Habits ◽

Diffusion Method ◽

Disk Diffusion Method ◽

E Coli ◽

Pcr Method ◽

Horticultural Products

The present study aimed at biochemical and molecular characterization ofEscherichia colistrains isolated from horticultural products and irrigation water of Cotonou. The samples were collected from 12 market gardeners of 4 different sites. Rapid’E. colimedium was used for identification ofE. colistrains and the antimicrobial susceptibility was performed by the agar disk diffusion method. Theβ-lactamases production was sought by the liquid acidimetric method. The genes coding forβ-lactamases and toxins were identified by PCR method. The results revealed that about 34.95% of the analyzed samples were contaminated byE. coli. Cabbages were the most contaminated byE. coli(28.26%) in dry season. All isolated strains were resistant to amoxicillin. The penicillinase producingE. colicarriedblaTEM(67.50%),blaSHV(10%), andblaCTX-M(22.50%) genes. The study revealed that the resistance genes such as SLTI (35.71%), SLTII (35.71%), ETEC (7.15%), and VTEC (21.43%) were carried. Openly to the found results and considering the importance of horticultural products in Beninese food habits, it is important to put several strategies aiming at a sanitary security by surveillance and sensitization of all the actors on the risks of some practices.

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Comparison of Escherichia coli isolates implicated in human urinary tract infection and avian colibacillosis

Microbiology ◽

10.1099/mic.0.27499-0 ◽

2005 ◽

Vol 151 (6) ◽

pp. 2097-2110 ◽

Cited By ~ 227

Author(s):

Kylie E. Rodriguez-Siek ◽

Catherine W. Giddings ◽

Curt Doetkott ◽

Timothy J. Johnson ◽

Mohamed K. Fakhr ◽

...

Keyword(s):

Escherichia Coli ◽

Urinary Tract Infection ◽

Urinary Tract ◽

Virulence Genes ◽

Phylogenetic Group ◽

Human Beings ◽

Phylogenetic Groups ◽

E Coli ◽

Antimicrobial Susceptibility Patterns of Escherichia coli among Tunisian Outpatients with Community-Acquired Urinary Tract Infection (2012-2018)

Current Urology ◽

10.1159/000499238 ◽

2020 ◽

Vol 14 (4) ◽

pp. 200-205

Author(s):

Nawel Daoud ◽

Manel Hamdoun ◽

Hela Hannachi ◽

Chedlia Gharsallah ◽

Wiem Mallekh ◽

...

Keyword(s):

Escherichia Coli ◽

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Clavulanic Acid ◽

Antimicrobial Susceptibility ◽

Diffusion Method ◽

E Coli ◽

Amoxicillin Clavulanic Acid ◽

Susceptibility Patterns

Introduction: Community-acquired urinary tract infection is one of the most common reasons for consultation in everyday practice; it represents a major source of antibiotic consumption. Escherichia coli (E. coli) is the main pathogen incriminated. Objective:· The aim of this study was to evaluate antimicrobial susceptibility patterns of community-acquired uropathogenic E coli throughout a 7-year period. Methodology: All strains of E. coli isolated from urine samples between January 1st 2012 and December 31st 2018 were included. Presence of ≥ 103 CFU/ml in urine culture media was considered as significant for urinary tract infection. The identification of E. coli strains was realized using standard laboratory techniques. Antibiotic susceptibility testing was performed using the disk diffusion method according to the CA-SFM/ EUCAST criteria. Results: A total of 1,335 E. coli strains were isolated. Overall susceptibility rates to antimicrobial agents were as follows: ampicillin 39.1%, amoxicillin-clavulanic acid 64.9%, cefotaxime 94.9%, trimethoprim/sulfamethox-azole 67.6%, ciprofloxacin 89.2%, ofloxacin 86.9%, amikacin 98.6%, gentamicin 93.9%, nitrofurantoin 97.6% and fosfomycin 99.3%. All isolates were susceptible to carbapenems. The frequency of extended spectrum beta-lactamases-producing E. coli strains was 4.7%. Susceptibility rates of E. coli for ampicillin, trimethoprim/sulfamethoxazole and amikacin remained relatively stable over the study period, whereas susceptibility to amoxicillin-clavulanic acid, cefotaxime and fluoroquinolones showed a 2-phase pattern. As for gentamicin, a continuous decrease in susceptibility rates was observed. Conclusion: Antimicrobial susceptibility profiles of uropathogenic E. coli are constantly changing, due to modifications in the antibiogram interpretation criteria and antibiotic prescription habits. Rigorous surveillance of resistance rate is necessary to determine appropriate empirical treatment and limit the spread of multiresistant strains.

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