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ullah S, Saadaat R, Hamidi H, Haidary AM. Proteus mirabilis: A rare cause of pneumonia, radiologically mimicking malignancy of the lung. Clin Case Rep 2023; 11:e7937. [PMID: 37736480 PMCID: PMC10509339 DOI: 10.1002/ccr3.7937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/12/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023] Open
Abstract
Key clinical message Lesions that are suspected for malignancy need be managed by a multidisciplinary team. Utilization of radiological as well as pathological diagnostic modalities ensures correct diagnosis and thus timely intervention. Abstract Introduction Proteus mirabilis is a Gram-negative rod. It is a highly motile bacterium that belongs to the Enterobacteriaceae. Lung infection and pneumonia caused by p. mirabilis is extremely rare and occurs in patients with chronic debilitation or chronic lung disease. Case Presentation A 65-year-Old Woman presented with dry cough, dyspnoea on exertion, and chest pain of 4 months' duration. She received multiple medications including antibiotics but without any resolution of her symptoms. Computed Tomography scan of the chest was performed reported a tumor in the upper lobe of the left lung with multiple associated pulmonary nodules. The impression was that of metastatic lung disease with superimposed acute infection. Accordingly, the patient was reevaluated and a diagnostic bronchoscopy with multiple endobronchial biopsies and broncho-alveolar lavage was done. The gram stain showed Gram-Negative Bacilli and the bacteria identified P. mirabilis. Conclusion Mass lesions suspected for malignancy should be managed with involvement of multiple medical disciplines, to ensure correct and timely diagnosis. This is to avoid miss-management.
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Affiliation(s)
- Saif ullah
- Department of Internal MedicineFrench Medical Institute for Mothers and Children (FMIC)KabulAfghanistan
| | - Ramin Saadaat
- Department of Pathology and Clinical LaboratoryFrench Medical Institute for Mothers and Children (FMIC)KabulAfghanistan
| | - Hidayatullah Hamidi
- Department of RadiologyFrench Medical Institute for Mothers and ChildrenKabulAfghanistan
| | - Ahmed Maseh Haidary
- Department of Pathology and Clinical LaboratoryFrench Medical Institute for Mothers and Children (FMIC)KabulAfghanistan
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Chao CM, Lai CC, Yu WL. Epidemiology of extended-spectrum β-lactamases in Enterobacterales in Taiwan for over two decades. Front Microbiol 2023; 13:1060050. [PMID: 36762100 PMCID: PMC9905819 DOI: 10.3389/fmicb.2022.1060050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023] Open
Abstract
The emergence of antimicrobial resistance among microorganisms is a serious public health concern, and extended-spectrum β-lactamases (ESBL)-producing Enterobacterales is one of the major concerns among antibiotic-resistant bacteria. Although the prevalence of ESBL in Enterobacterales has been increasing with time, the prevalence of ESBL could differ according to the species, hospital allocation, sources of infections, nosocomial or community acquisitions, and geographic regions. Therefore, we conducted a comprehensive review of the epidemiology of ESBL-producing Enterobacterales in Taiwan. Overall, the rates of ESBL producers are higher in northern regions than in other parts of Taiwan. In addition, the genotypes of ESBL vary according to different Enterobacterales. SHV-type ESBLs (SHV-5 and SHV-12) were the major types of Enterobacter cloacae complex, but Serratia marcescens, Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae were more likely to possess CTX-M-type ESBLs (CTX-M-3 and CTX-M-14). Moreover, a clonal sequence type of O25b-ST131 has been emerging among urinary or bloodstream E. coli isolates in the community in Taiwan, and this clone was potentially associated with virulence, ESBL (CTX-M-15) production, ciprofloxacin resistance, and mortality. Finally, the evolution of the genetic traits of the ESBL-producing Enterobacterales isolates helps us confirm the interhospital and intrahospital clonal dissemination in several regions of Taiwan. In conclusion, continuous surveillance in the investigation of ESBL production among Enterobacterales is needed to establish its long-term epidemiology.
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Affiliation(s)
- Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Taiwan,Department of Dental Laboratory Technology, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wen-Liang Yu
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan,Department of Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan,*Correspondence: Wen-Liang Yu,
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Kato K, Matsumura Y, Yamamoto M, Nagao M, Takakura S, Ichiyama S. Regional Spread of CTX-M-2-ProducingProteus mirabiliswith the Identical Genetic Structure in Japan. Microb Drug Resist 2017; 23:590-595. [DOI: 10.1089/mdr.2016.0148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Karin Kato
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Anesthesia, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Yamamoto
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shunji Takakura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Ichiyama
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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The impact of production of extended-spectrum β-lactamases on the 28-day mortality rate of patients with Proteus mirabilis bacteremia in Korea. BMC Infect Dis 2017; 17:327. [PMID: 28468622 PMCID: PMC5415711 DOI: 10.1186/s12879-017-2431-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/28/2017] [Indexed: 12/26/2022] Open
Abstract
Background The incidence of Proteus mirabilis antimicrobial resistance, especially that mediated by extended-spectrum β-lactamases (ESBLs), has increased. We investigated the impact of ESBL production on the mortality of patients with P. mirabilis bacteremia in Korea. Methods Patients diagnosed with P. mirabilis bacteremia between November 2005 and December 2013 at a 2000-bed tertiary care center in South Korea were included in this study. Phenotypic and molecular analyses were performed to assess ESBL expression. Characteristics and treatment outcomes were investigated among ESBL-producing and non-ESBL-producing P. mirabilis bacteremia groups. A multivariate analysis of 28-day mortality rates was performed to evaluate the independent impact of ESBLs. Results Among 62 P. mirabilis isolates from 62 patients, 14 expressed ESBLs (CTX-M, 2; TEM, 5; both, 6; other, 1), and the 28-day mortality rate of the 62 patients was 17.74%. No clinical factor was significantly associated with ESBL production. The 28-day mortality rate in the ESBL-producing group was significantly higher than that in the non-ESBL-producing group (50% vs. 8.3%, p = 0.001). A multivariate analysis showed that ESBL production (odds ratio [OR], 11.53, 95% confidence interval [CI], 2.11–63.05, p = 0.005) was independently associated with the 28-day mortality rate in patients with P. mirabilis bacteremia. Conclusions ESBL production is significantly associated with mortality in patients with bacteremia caused by P. mirabilis. Rapid detection of ESBL expression and prompt appropriate antimicrobial therapy are required to reduce mortality caused by P. mirabilis bacteremia.
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Borgogna TR, Borgogna JL, Mielke JA, Brown CJ, Top EM, Botts RT, Cummings DE. High Diversity of CTX-M Extended-Spectrum β-Lactamases in Municipal Wastewater and Urban Wetlands. Microb Drug Resist 2015; 22:312-20. [PMID: 26670020 DOI: 10.1089/mdr.2015.0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The CTX-M-type extended-spectrum β-lactamases (ESBLs) present a serious public health threat as they have become nearly ubiquitous among clinical gram-negative pathogens, particularly the enterobacteria. To aid in the understanding and eventual control of the spread of such resistance genes, we sought to determine the diversity of CTX-M ESBLs not among clinical isolates, but in the environment, where weaker and more diverse selective pressures may allow greater enzyme diversification. This was done by examining the CTX-M diversity in municipal wastewater and urban coastal wetlands in southern California, United States, by Sanger sequencing of polymerase chain reaction amplicons. Of the five known CTX-M phylogroups (1, 2, 8, 9, and 25), only genes from groups 1 and 2 were detected in both wastewater treatment plants (WWTPs), and group 1 genes were also detected in one of the two wetlands after a winter rain. The highest relative abundance of blaCTX-M group 1 genes was in the sludge of one WWTP (2.1 × 10(-4) blaCTX-M copies/16S rRNA gene copy). Gene libraries revealed surprisingly high nucleotide sequence diversity, with 157 new variants not found in GenBank, representing 99 novel amino acid sequences. Our results indicate that the resistomes of WWTPs and urban wetlands contain diverse blaCTX-M ESBLs, which may constitute a mobile reservoir of clinically relevant resistance genes.
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Affiliation(s)
- Timothy R Borgogna
- 1 Department of Biology, Point Loma Nazarene University , San Diego, California
| | | | - Jenna A Mielke
- 1 Department of Biology, Point Loma Nazarene University , San Diego, California
| | - Celeste J Brown
- 2 Department of Biological Sciences, Institute for Bioinformatics and Evolutionary Studies (IBEST), University of Idaho , Moscow, Idaho
| | - Eva M Top
- 2 Department of Biological Sciences, Institute for Bioinformatics and Evolutionary Studies (IBEST), University of Idaho , Moscow, Idaho
| | - Ryan T Botts
- 3 Department of Mathematics, Information, and Computer Sciences, Point Loma Nazarene University , San Diego, California
| | - David E Cummings
- 1 Department of Biology, Point Loma Nazarene University , San Diego, California
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Ryou SH, Bae JW, Baek HJ, Lee DH, Lee SW, Choi GH, Han KH, Kim SW, Kim H, Hong G. Pulmonary Pneumatocele in a Pneumonia Patient Infected with Extended-Spectrum β-Lactamase Producing Proteus mirabilis. Tuberc Respir Dis (Seoul) 2015; 78:371-4. [PMID: 26508927 PMCID: PMC4620333 DOI: 10.4046/trd.2015.78.4.371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/15/2015] [Accepted: 06/19/2015] [Indexed: 11/24/2022] Open
Abstract
Pulmonary pneumatoceles are air-filled thin-walled spaces within the lung and are rare in adult cases of pneumonia. We report the case of a 74-year-old male who was admitted with a cough and sputum production. He had been treated with oral dexamethasone since a brain tumorectomy 6 months prior. Contrast-enhanced computed tomography (CT) of the chest revealed a large pneumatocele in the right middle lobe and peripheral pneumonic consolidation. Bronchoalveolar lavage was performed; cultures identified extended-spectrum β-lactamase (ESBL) producing Proteus mirabilis. A 4-week course of intravenous ertapenem was administered, and the pneumatocele with pneumonia resolved on follow-up chest CT. To the best of our knowledge, this is the first reported case of pulmonary pneumatocele caused by ESBL-producing P. mirabilis associated with pneumonia.
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Affiliation(s)
- Sung Hyeok Ryou
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jong Wook Bae
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Hyun Jin Baek
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Doo Hyuk Lee
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Won Lee
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Gyu Ho Choi
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Kyu Hyung Han
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Se Weon Kim
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Hyunbeom Kim
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Goohyeon Hong
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Apisarnthanarak A, Kiratisin P, Mundy LM. Clinical and Molecular Epidemiology of Healthcare-Associated Infections Due to Extended-Spectrumβ-Lactamase (ESBL)–Producing Strains ofEscherichia coliandKlebsiella pneumoniaeThat Harbor Multiple ESBL Genes. Infect Control Hosp Epidemiol 2015; 29:1026-34. [DOI: 10.1086/591864] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objectives.To characterize healthcare-associated infections due to extended-spectrumβ-lactamase (ESBL)-producing strains ofEscherichia coliandKlebsiella pneumoniaethat harbor multiple ESBL genes, as opposed to a single ESBL gene.Methods.All patients with a confirmed healthcare-associated infection due to an ESBL-producing strain ofE. coliorK. pneumoniaewere enrolled in the study. Molecular typing of isolates was performed, and the comparative risks and outcomes of patients were analyzed.Results.Among 71 patients with healthcare-associated infection due to an ESBL-producing strain ofE. coliorK. pneumoniae, the gene for CTX-M, with or without other ESBL genes, was identified in all 51 (100%) of the patients infected with anE. colistrain and in 18 (90%) of the 20 patients infected with aK. pneumoniaestrain. Of these 71 patients, 17 (24%) met the definition of healthcare-associated infection due to an ESBL-producing strain that harbored multiple genes; in multivariate analysis, previous exposure to 3 or more classes of antibiotics (adjusted odds ratio, 4.5 [95% confidence interval, 1.7-75.2]) was the sole risk factor for healthcare-associated infection due to an ESBL-producing strain that harbored multiple ESBL genes. Isolates recovered from patients with healthcare-associated infection due to an ESBL-producing strain that harbored multiple ESBL genes were more resistant to various antibiotic classes, and, compared with patients with healthcare-associated infection due to an ESBL-producing strain that harbored a single ESBL gene, they were more likely to have ineffective initial empirical antimicrobial therapy (52% vs 94%; odds ratio, 5.1 [95% confidence interval, 1.04-14.5]).Conclusions.CTX-M ESBL is highly prevalent in Thailand. Patients with healthcare-associated infection due to an ESBL-producing strain that harbored multiple ESBL genes were more likely to have had ineffective initial empirical antimicrobial therapy, and, given that antibiotic selection pressure was the only associated risk, we suggest focused antimicrobial stewardship programs to limit the emergence and spread of healthcare-associated infection due to ESBL-producing strains in this middle-income country.
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Huang CW, Chien JH, Peng RY, Tsai DJ, Li MH, Lee HM, Lin CF, Lee MC, Liao CT. Molecular epidemiology of CTX-M-type extended-spectrum β-lactamase-producing Proteus mirabilis isolates in Taiwan. Int J Antimicrob Agents 2014; 45:84-5. [PMID: 25446905 DOI: 10.1016/j.ijantimicag.2014.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Chien-Wen Huang
- Division of Chest Medicine, Feng Yuan Hospital, Ministry of Health and Welfare, Executive Yuan, Taiwan, ROC
| | - Ju-Huei Chien
- Department of Laboratory Medicine, Tzu Chi Hospital, Taichung Branch, Taichung, Taiwan, ROC
| | - Ru-Yan Peng
- Institute of Biotechnology, Central Taiwan University of Science and Technology, Taiwan, ROC
| | - De-Jiun Tsai
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, No. 660 Buzih Road, Beitun District, Taichung City 40601, Taiwan, ROC
| | - Ming-Hsien Li
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, No. 660 Buzih Road, Beitun District, Taichung City 40601, Taiwan, ROC
| | - Hsien-Ming Lee
- Institute of Biotechnology, Central Taiwan University of Science and Technology, Taiwan, ROC
| | - Chuen-Fu Lin
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, No. 660 Buzih Road, Beitun District, Taichung City 40601, Taiwan, ROC
| | - Mong-Chuan Lee
- Institute of Biotechnology, Central Taiwan University of Science and Technology, Taiwan, ROC
| | - Chao-Tsai Liao
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, No. 660 Buzih Road, Beitun District, Taichung City 40601, Taiwan, ROC.
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Zhao WH, Hu ZQ. Epidemiology and genetics of CTX-M extended-spectrum β-lactamases in Gram-negative bacteria. Crit Rev Microbiol 2012; 39:79-101. [PMID: 22697133 PMCID: PMC4086240 DOI: 10.3109/1040841x.2012.691460] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CTX-M enzymes, the plasmid-mediated cefotaximases, constitute a rapidly growing family of extended-spectrum β-lactamases (ESBLs) with significant clinical impact. CTX-Ms are found in at least 26 bacterial species, particularly in Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. At least 109 members in CTX-M family are identified and can be divided into seven clusters based on their phylogeny. CTX-M-15 and CTX-M-14 are the most dominant variants. Chromosome-encoded intrinsic cefotaximases in Kluyvera spp. are proposed to be the progenitors of CTX-Ms, while ISEcp1, ISCR1 and plasmid are closely associated with their mobilization and dissemination.
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Affiliation(s)
- Wei-Hua Zhao
- Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan.
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Sohn KM, Kang CI, Joo EJ, Ha YE, Chung DR, Peck KR, Lee NY, Song JH. Epidemiology of ciprofloxacin resistance and its relationship to extended-spectrum β-lactamase production in Proteus mirabilis bacteremia. Korean J Intern Med 2011; 26:89-93. [PMID: 21437168 PMCID: PMC3056262 DOI: 10.3904/kjim.2011.26.1.89] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 08/30/2010] [Accepted: 09/28/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the clinical features of ciprofloxacin-resistant Proteus mirabilis bacteremia and risk factors for ciprofloxacin resistance. METHODS From October 2000 to July 2009, 37 patients with clinically significant P. mirabilis bacteremia were identified and data from patients with ciprofloxacin-resistant and ciprofloxacin-susceptible P. mirabilis bacteremia were compared. RESULTS The most common underlying diseases were neurologic disease (37.8%) and solid tumors (29.7%). The most common site of infection was the urinary tract (35.1%). Ten of the 37 patients (27.0%) were infected with ciprofloxacin-resistant isolates, and univariate analysis revealed a significant relationship between ciprofloxacin-resistant P. mirabilis bacteremia and neurologic disease, recent operation, L-tube insertion, percutaneous tube use, and extended-spectrum β-lactamase (ESBL) production (all p < 0.05). ESBL was detected in six of 10 (60%) ciprofloxacin-resistant isolates, while only three of 27 (11%) ciprofloxacin-susceptible isolates produced ESBL (p = 0.005). In a logistic regression analysis, ESBL production remained a significant factor associated with ciprofloxacin resistance, after adjusting for other variables. CONCLUSIONS These data indicate a close association between ciprofloxacin resistance and ESBL-production in P. mirabilis bacteremia. This association is particularly troublesome because the therapeutic options for serious infections caused by ESBL-producing P. mirabilis are severely restricted.
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Affiliation(s)
- Kyung Mok Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Jeong Joo
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Eun Ha
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Plasmid-mediated 16S rRNA methylases among extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates. Antimicrob Agents Chemother 2008; 52:4526-7. [PMID: 18838598 DOI: 10.1128/aac.00882-08] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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