Molecular characterization of ESBL and carbapenemase producing Uropathogenic Escherichia coli in hospitalized patients, Tehran, Iran

Molecular characterization of ESBL and carbapenemase producing Uropathogenic Escherichia coli in hospitalized patients, Tehran, Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Molecular characterization of ESBL and carbapenemase producing Uropathogenic Escherichia coli in hospitalized patients, Tehran, Iran Mehdi Bozorgi Mazandarani, Mohammad Kargar, Farshid Kafilzadeh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4330353/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Uropathogenic Escherichia coli (UPEC) with antibiotic resistance and virulence factors can cause urinary tract infections (UTIs). The aim of this survey was to evaluate the genetic characteristic of extended-spectrum beta-lactamases (ESBLs) and carbapenemase producing UPEC (CP-UPEC) isolates. Methods In this cross-sectional study, 300 UPEC isolates were collected from the urine samples of patients hospitalized between January 2019 and December 2020. The antibiotic susceptibility of the isolates was evaluated by disk diffusion method. The minimum inhibitory concentration (MIC) of meropenem and CAZ/AVI were determined by E-test, and that of colistin was determined by micro broth dilution method. Biofilm formation was assessed by microtiter plate assay. Antibiotic-resistant genes, virulence factors, phylogroups, and serogroups were detected by polymerase chain reaction (PCR) technique. The relationship between the isolates was evaluated by pulsed-field gel electrophoresis (PFGE) typing. Sequence type 131 (ST131) isolates were identified by PCR and confirmed by multilocus sequence typing. Results A total of 100 isolates were collected from UTI patients which 36% (n = 36) of isolates were ESBL producing E. coli (EP- E.coli ). Among 36 EP- E.coli isolates, 14 (38.8%), 33.3% (n = 12), 25% (n = 9), and 16.6% (n = 6) were temocillin, carbapenem, CAZ/AVI, and colistin resistant. 33.5% (n = 11/36) of EP- E.coli were carbapnememase producing E.coli (CP- E.coli ). Also, of these 36 isolates, 29 (80.5%) harbored bla CTX−M gene and 7 (19.4%) were detected to be ST131. In addition, bla OXA−48 and bla NDM carbapenemase genes existed in CP- E.coli isolates. Virulence genes were mostly fimH (97.2%; n = 35), iutA (86.1%; n = 31), and fuA (80.5%; n = 29). O1 (36.1%), and O25 (22.2%) were predominant serogroups. Phylogroup typing showed that 52.7% of isolates belonged to B2 phylogroup, and PFGE typing showed 32 singletons and 2 clusters. Conclusions Our findings revealed the high prevalence of antibiotic resistant in EP- E.coli isolates, likely due to the excess clinical use of antibiotics. In addition CP- E.coli isolates belonging to ST131-O25-B2 could carry bla NDM and bla OXA−48 genes and transferred between different ward of our hospital, since there are limited options to treat the infection caused by these isolates, surveillance is needed to control the spread of such multidrug-resistant strains of E. coli . Uropathogenic Escherichia coli virulence typing carbapenemase serogrouping phylogroups Figures Figure 1 Introduction Enterobacteriaceae includes several important human pathogens, such as Escherichia coli , Klebsiella pneumoniae , and Salmonella species ( 1 ). Uropathogenic E. coli (UPEC) as a specific pathotype of E. coli causing urinary tract infections (UTI) encodes various adhesive and secretory virulence factors ( 2 ). E. coli , based on their genetic characteristics classified into various phylogroups, which certain phylogroups such as B2 and D are known to be associated with specific types of pathogenic E. coli strains such as sequence type 131 (ST131) known clone causing significant extra intestinal infection worldwide ( 3 ). Antibiotic resistance in E. coli has recently become a significant concern, due to the ability of these bacteria to acquire and spread resistance genes by various mechanisms such as production of beta-lactamases ( 4 ). Extended-spectrum beta-lactamases producing E. coli (EP- E.coli ) hydrolyze beta-lactams causes resistant to b-lactams ( 5 ). Carbapenemase-producing (CP- E. coli ) can hydrolyze carbapenem antibiotics, as a last resort treatment option for multidrug-resistant (MDR) bacterial infections ( 6 ). The production of carbapenemases by UPEC strains poses a significant public health burden because of limited treatment options ( 7 ). In addition through biofilm formation, E. coli can provide the environment for limited antibiotic penetration and exchange of virulence and resistant genes ( 8 ). The ESBL and carbapenemase production indicates a high level of antibiotic resistance, and healthcare providers must rely on alternative antibiotics such as colistin, temocillin, and CAZ/AVI. Herein, we investigated the molecular characteristics, antibiotic resistance and virulence factors in EP- E. coli causing urinary tract infection in hospital. Materials and methods Sample collection A total of 300 clinical E. coli isolates were collected from UTI who have hospitalized in various hospitals in Tehran during January 2019 to December 2020. The E. coli isolates were identified by CHROM agar medium (HiMedia Co., India), biochemical (catalase, indole, and citrate) tests, and API-20E test strips (BioMérieux, France) ( 9 ). Antibiotic susceptibility test In accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines and using the disc diffusion method on Mueller-Hinton agar (Conda, Spain), we performed the antibiotic susceptibility test. The following antibiotics were used in the test: nitrofurantoin (NFT; 300 µg), fosfomycin (FO; 30 µg), gentamycin (GEN; 10 µg), ampicillin (AMP; 10 µg), aztreonam (ATM; 30 µg), trimethoprim/sulfamethoxazole (SXT; 25 µg), ciprofloxacin (CIP; 5 µg), nalidixic acid (NAL; 30 µg), cefotaxime (CTX; 30 µg), ceftazidime (CZA; 30 µg), imipenem (IPM; 10 µg), meropenem (Mpm; 10 µg), ertapenem (ETP; 10 µg), piperacillin/tazobactam (TZP; 100/10 µg), ampicillin/sulbactam (SAM; 10/10 µg), amoxicillin/clavulanic acid (AMC; 20/10 µg), and amikacin (AMK; 30 µg), which all were obtained from Mast Group Ltd., Merseyside, UK. Klebsiella oxytoca ATCC 13182, and E. coli ATCC 25922 were used as control strains ( 10 – 12 ). ESBL and carbapenemase production determination The identification of ESBL-producing isolates was determined by E-test (BioMérieux’) and combination disk test recommended by the CLSI. Klebsiella pneumoniae ATCC 700603 was used as a positive control strain and E. coli ATCC 25922 as a negative control strain. Identification of carbapenemase-producing isolates was confirmed by the combined disk test, including Mpm ± EDTA (0.5 M), and Carba NP test, following the CLSI guideline ( 10 ). Antibiotic resistance in UPEC isolates The minimum inhibitory concentrations (MICs) of Mpm- and carbapenem-resistant E. coli isolates were determined by E-test method (BioMérieux) according to a protocol provided by the manufacturer. Carbapenem-resistant E. coli isolates were resistant to ETP, IPM, and Mpm, with a MIC ≥ 4 µg/ml against Mpm. E. coli ATCC 25922 strain was considered as the control strain ( 10 ). Temocillin resistance was determined by disk diffusion method on Mueller–Hinton agar using temocillin disk (30 µg; Liofilchem, Italy). Temocillin zone diameters were determined, and the results were interpreted as per the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. The MIC of colistin (Sigma Chemical Company, St. Louis, MO, USA) was obtained by the broth microdilution method. E. coli ATCC 25922 and Proteus mirabilis ATCC 12453 were employed as the control strains. The isolates with MIC > 4 were considered as colistin resistant. Biofilm formation assay The biofilm production was quantified using the microtiter plate assay according to prior studies ( 13 , 14 ). In brief, bacteria cultivated in trypticase soy broth (Merck, USA) containing 1% glucose were incubated at 37°C for 24 h. the ELISA reader was employed for the absorbance determination at the wavelength of 590 nm. The biofilm formation level and OD of isolates were determined as explained before ( 15 ). Amplification of genes by polymerase chain reaction (PCR) DNA was extracted using the boiling method. The PCR test was applied for the amplification of resistant genes ( bla CTX−M , bla TEM , bla SHV , bla NDM , bla VIM , bla IMP , bla KPC , and bla OXA−48 ), virulence genes ( piccsgA , iutA , ibeA , vat , hlyA , sat , traT , cdt , cnf1 , kpsMTII , and tcpC ), serogroups (O1, O2, O4, O6, O7, O12, O15, O16, O18, O25, O75, O157 types), and phylogroups (TspE4.C2, chuA and yjaA ) by specific primers. PCR conditions and primers have been described in previous studies ( 16 – 18 ). The PCR products were sequenced, and the DNA sequences of the amplified target sites were aligned and compared with those in the National Centre for Biotechnology Information database using the BLAST. Genetic relatedness of the isolates The chromosomal DNA was digested by the restriction enzyme Xba I and then subjected to pulse-field gel electrophoresis (PFGE) analysis according to the standard protocols. The DNA of Salmonella serotype Braenderup strain H8912 was also treated with Xba I and used as a molecular weight standard. The dendrogram was constructed with the aid of Gel Compare II. Isolates with a dice similarity index ≥ 80% were considered to be in the same PFGE cluster. Molecular characterization of sequence type 131 (ST131) clone The ST131 clones were identified by PCR of ST131-specific single nucleotide polymorphisms in mdh and gyr B genes ( 19 , 20 ). The isolates identified as ST131 using PCR were further analyzed by applying multilocus sequence typing 20 . Statistical analysis The statistical analysis of the data was carried out by the R software version 3.3.3 and interpreted based on the frequency distribution and percentage. Data with the p- value less than or equal to 0.05 (95% confidence interval) were regarded as statistically significant. Results Antimicrobial resistance patterns of isolates Among 300 urine samples included in this study, 100 E. coli isolates were detected. The demographic information and distribution of E. coli isolates are shown in Table 1. The isolates showed resistance patterns to the following antibiotics: AMP (92%; n=92), CTX (85%; n=85) CZA (74%; n=74), SXT (63%; n=63), ATM (54%; n=54), NAL (51%; n=51), CIP (49%; n=49), SAM (38%; n=38), amoxicillin-clavulanic acid (31%; n=31), TZP (26%; n=26), NFT (21%; n=21), AMK (20%; n=20), gentamicin (18%; n=18), FO (18%; n=18), ETP (12%; n=12), IPM (12%; n=12), and Mpm (%11; n=11). A total of 36/100 (36%) E. coli isolates were phenotypically ESBL producers. In ESBL-producing isolates, 14/36 (38.8%) and 12/36 (33.3%) were temocillin and carbapenem resistant, respectively, and 11/36 (30.5%) were CP- E.coli , with a MIC≥4 µg/ml against Mpm. In addition, 9/36 (25%) and 6/36 (16.6%) of the isolates were resistant to CAZ/AVI (MIC≥128 µg/ml) and colistin (MIC>4 µg/ml), respectively. The E. coli isolates indicated multiple resistance to antibiotics cephalosporins, sulfonamides, and fluoroquinolones, and 48/100 (48%) of the isolates were classified as MDR. Prior antibiotic consumption and hospitalization were significant risk factors for the isolation of ESBL E. coli isolates ( p =0.01 and p =0.02). Noticeably, there was no association between age, gender, different wards and underlying diseases with EP- E. coli isolation ( p >0.05). Table 1. Epidemiological characteristics of ESBL and non-ESBL-producing E. coli P Non-ESBL No. (%) (N=64) ESBL No. (%) (N=36) Total (N=100) Characteristics 0.907 51.5 (n=33) 48.5 (n=31) 52.8 (n=19) 47.2 (n=17 ) 52 48 Gender Male Female 0.315 20.3 (n=13) 34.3 (n=22) 45.3 (n=29) 13.8 (n=5) 25.0 (n=9) 6.1 (n=22) 18 31 51 Age 60 0.933 15.6 (n=10) 40.6 (n=26) 26.5 (n=17) 12.5 (n=8) 4.6 (n=3) 22.2 (n=8) 38.8 (n=14) 25.0 (n=9) 11.11 (n=4) 2.7 (n=1) 18 40 26 12 4 Clinical distribution ICU Nephrology Hematology Emergency Other 0.022 54.6 (n=35) 45.3 (n=29) 77.7 (n=28) 22.3 (n=8) 63 37 Healthcare occupation Positive Negative 0.01 45.3 (n=29) 54.6 (n=35) 88.8 (n=32) 11.1 (n=4) 61 39 Prior antibiotic use Positive Negative 0.04 17.2 (n=12) 38.8 (n=14) 26 Biofilm formation 0.937 26.5 (n=17) 18.7 (n=12) 12.5 (n=8) 10.9 (n=7) 15.6 (n=5) 6.25 (n=4) 17.1 (n=11) 27.7 (n=10) 22.2 (n=8) 13.8 (n=5) 13.8 (n=5) 8.3 (n=3) 0.0 (n=0) 13.8 (n=5) 27 20 13 12 8 4 16 Underlying disease Diabetes Cancer Kidney disease Liver disease Hart disease Other Non Underlying disease Prevalence of ESBL and carbapenemase genes Among the 36 ESBL-producing E. coli isolates surveyed, 29 (80.5%), 19 (52.7%), and 17 (47.2%) harbored bla CTX-M , bla TEM , and bla SHV genes, respectively. All 36 (100%) isolates carried the bla CTXM gene and was also ESBL producers. Among 11 carbapenemase-producing E. coli isolates, 54.5% (n=6) and 18% (n=2) harbored bla NDM and bla OXA - 48 genes, respectively, and 27.2% (n=3) of the isolates harbored both bla NDM and bla OXA - 48 genes . None of the isolates carried bla KPC , bla IMP , and bla VIM genes. Analysis of isolates by PFGE PFGE analysis of 36 EP- E. coli demonstrated 34 pulsotypes classified into 32 singletons with unique patterns, as well as 2 clusters, each consists of two strains numbered from P1 to P34. Distribution of pulsotypes in different hospital wards and different dates is shown in Figure 1. Results of biofilm formation Totally 26% (26/100) isolates were biofilm producer. As showed in table 1, Biofilm formation has significant association with EP- E. coli isolates ( p =0.04). In EP- E. coli 14 isolates were biofilm producers which 28.5% (n=4/14) was strong biofilm producers, while 57.1% (n=8/14) and 14.2 % (n=2/14) were moderate and weak biofilm producers, respectively. Recognition of phylogroups and serogroups The majority of the EP- E. coli isolates belonged to the phylogenetic groups B2 (52.7%; n=19/36) and D (33.3%; n=12/36), followed by groups B1 (8.3%; n=3/36), A (2.7%; n=1/36), and F (2.7%; n=1/36). Also, serogroup O1 was detected in 36.1% (n=13/36) of the isolates and then in serogroups O25 (22.2%; n=8/36), O75 (13.8%; n= 5/36), O18 (8.3; n=3/36), O15 (5.5; n=2/36), O4 (2.7%; n=1/36), and O16 (2.7%; n=1/36). The serogroup of 8.3% (n=3/36) of the isolates could not be detected. Identification of virulence factor genes Among the EP- E. coli , 97.2% (n=35), 86.1% (n=31), 83.3% (n=30), 80.5% (n=29), 33.3% (n=12), 30.5% (n=11), and 27.7% (n=10) carried fimH , iutA , fyuA , inh , traT , papП , and csgA genes, respectively. In addition, 30.5% (n=11), 27.7% (n=10), 25% (n=9), 19.4% (n=7), 16.6% (n=6), 13.8% (n=5), 13.8% (n=5), and 8.33% (n=3) carried fimA , ompT , usp , sfa/foc , hly , cnf-1 , afa , and iroN , respectively. Detection of ST131 clone A total of 19.4% (n=7/36) isolates in EP- E. coli isolates were identified as ST131. All the isolates (100%; n=7/7) were detected as O25b-ST131 clone, which 57.1% (n=4/7) were carbapenemase-producing isolates containing bla CTX-M , bla NDM and bla OXA-48 genes (Table 2). As shown in Table 2, most of the carbapenemase-producing E. coli isolates were serogroup O1, and three of these isolates containing bla NDM and bla oxa-48 genes belonged to O25 (ST131 clone). Table 2. Characteristics of Carbapenemase-producing E.coli isolates ESBL Mpm MIC (µg/mL) CTX MIC (µg/mL) CAZ/AVI MIC (µg/mL) Colistin MIC (µg/mL) Temocillin sensitivity Resistance genes Phyl/Sero Sequence typing Yes 64 32 128 0.5 R CX-M/OXA-48/NDM B2/O25 ST131 Yes 16 32 128 16 R CTX-M/NDM B1/O1 Non-ST131 Yes 8 32 128 32 R CTX-M/NDM B2/O1 Non-ST131 Yes 8 32 128 0.5 S CTX-M/NDM B2/O25 ST131 Yes 8 32 128 1 R CX-M/OXA-48/NDM B2/O25 ST131 Yes 128 32 128 16 R CTX-M/NDM B2/O1 Non-ST131 Yes 4 32 0.5 0.5 R CTX-M/OXA-48 B2/O1 Non-ST131 Yes 128 32 128 0.5 R CX-M/OXA-48/NDM B2/O25 ST131 Yes 4 32 0.5 1 S CTX-M/OXA-48 B1/O1 Non-ST131 Yes 4 32 128 32 R CTX-M /NDM B2/O1 Non ST131 Yes 4 32 128 0.5 R CTX-M/NDM B2/O16 Non-ST131 Discussion E. coli is one of the most causative agent of UTI in the world, and some strains of E. coli , owing to certain attributes such as high virulence factors and high antibiotic resistance, are rapidly spreading in the globe, like clone ST131 E. coli ( 21 ). This study found a high prevalence of MDR E. coli isolates and explored that the antibiotic resistant pattern of these isolates were similar to that reported in other studies in different clinical settings ( 22 , 23 ). Prior hospitalization and prior antibiotic consumption were significant risk factors for isolation of EP- E. coli isolates in patients. Several investigations have reported a connection between former antibiotic use, hospitalization, and isolation of MDR strains ( 24 – 26 ) Temocillin and carbapenems are two options for treating EP- E. coli . Temocillin is stable against ESBLs and AmpC b-lactamase and effective in the treatment of UTI infections ( 27 ). In our study, temocillin was active against 61.2% of ESBL-producing isolates; therefore, the susceptibility of the isolates to this antibiotic can be considered as an alternative treatment for such intricate infections. Carbapenems are typically used to treat complicated bacterial infections with EP- E. coli isolates, and the percentage of resistant to these antibiotics varies in different studies and has rapid growth, particularly in developing country, due to excessive use of this class of antibiotics ( 28 ). Herein, the majority of carbapenem-resistant E. coli isolates was resistant to most of available antibiotics; therefore, in some cases, colistin is often used for treating the infections caused by these isolates ( 29 ). The prevalence rate of colistin resistance varies in different countries, which the highest rate (19%) was found in Thailand, and the lowest rate (0.8%) was observed in South Korea ( 30 ). Colistin resistant in our study, indicating the high use of this antibiotic in the treatment of carbapenem-resistant isolates in Iran because of limited new antibiotic options. CAZ/AVI is recognized as a global new treatment alternative for carbapenem-resistant infections. Although this antibiotic is not admitted to our country as a treatment choice, its resistance rate has been reported. Resistance of CAZ/AVI in carbapenem-resistant isolates has increased to 71.4% in country with CAZ/AVI treatment and current studies reporting the high rate (25%) of CAZ/AVI resistance suggests that the emergence of its resistance is not related to the presence or absence of previous CAZ-AVI treatment ( 31 , 32 ). Based on PFGE pattern in the present study, similar genotypes were isolated from hospital wards in different times, indicating that some resistance strains have a common origin that can disseminate across hospital wards. Therefore, hospital infection control committee is required to identify the origin of these resistant isolates and employ effective health strategy to decrease the spread of resistant bacteria in the hospital ( 33 ). As emphasized in studies, the ICU which ST131 clone with similar pattern were collected is a major ward in disseminating resistant bacterial strains because patients are hospitalized in this ward for a long time, and they can be a source of infection. Hence, hospital infection control committee have to pay more attention to the control of dissemination of infection in hospitals via the patients, foods, water, doctors, staff, and bed by surveillance and finding the source of infection ( 32 ). The prevalence of ESBL and carbapenemase genes can vary depending on geographical locations, healthcare settings, and the population being studied. ESBL enzymes, which hydrolyze the cephalosporins (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and cefepime) and monobactams (aztreonam), are becoming a major challenge for treatment of pathogenic bacteria. However, the same as a previous study conducted in our country, the prevalence of CTX-M is high and noticeable ( 34 ). Carbapenemase genes are responsible for encoding enzymes that can break down and inactivate carbapenem antibiotics, which are considered last-resort antibiotics for treating severe bacterial infections. The prevalence of carbapenemase genes among carbapenem-resistant bacteria is influenced by factors such as antibiotic use, infection control practices, and the dissemination of resistant strains ( 35 , 36 ). In some parts of the world, the prevalence of carbapenemase genes can be relatively high, particularly in countries with high rates of antibiotic use and inadequate infection control measures, for instance, certain countries in Southeast Asia, the Middle East, and regions of Europe have reported high rates of bacteria producing carbapenemase ( 37 ). It is worth mentioning that surveillance data on the prevalence of carbapenemase genes can vary over time and across different studies ( 38 , 39 ). Local and regional surveillance programs, as well as molecular testing methods, are crucial for monitoring the prevalence and spread of carbapenemase genes. Based on available evidence, the global prevalence rate of biofilm formation is different, ranging between 56% and 100%. This observation shows that various factors, including different geographical areas, low-level hygiene, varying methods, can affect the biofilm formation. In our study, the same as other survey ( 40 ), there was an association between biofilm formation and antibiotic resistance ( p = 0.04), which could arise from the antibiotic misuse and its administration without prescription in our country. In our study, similar to Boroumand et al.’s study ( 40 ) and contrary to Rasoulinasab et al.’s study ( 41 ), fimH and iutA were the predominant and iroN was the lowest virulence factors. This variation in the prevalence rate of genes is possibly due to the different source of the samples. In this study, the B2 phylogroup was the predominant phylogroup. It has been reported that the prevalence rate of phylogroups is different in the phylogroup pattern of E. coli isolates, which could be ascribed to the source of isolates ( 3 , 42 , 43 ). However, the high prevalence rate of phylogroup B2 in our study was noticeable. One of the important sequence types with high antibiotic resistant in EP- E. coli isolates is ST131clone, as the causative agent of UTI. There are different reported rates of this clone in the world and it is also varied in different parts of our country which is probably due to varying times of studies conducted, geographical locations, and sample types ( 44 , 45 ). Isolation of carbapenem-resistant isolate ST131 in this study is a warning for more dissemination of carbapenem resistance genes in our country and in the world. Conclusions Our findings demonstrated a high prevalence of virulence genes and antibiotic resistance in E. coli which has been transferred between hospitalized patients. Hence, surveillance is needed to control the spread of MDR strains particularly in special wards. In addition, in the present study, CP- E. coli could carry bla NDM and bla OXA−48 genes belonging to ST131 O25/B2 with high antibiotic resistant, which remains a risk for treatment and dissemination of resistant genes in hospital. Therefore, rapid molecular detection of high-risk clones can be helpful in limiting the dissemination of such strains. Declarations Conflict of interest The authors declare they have no conflicts of interest. Acknowledgments The equipment support of this study by the Islamic Azad University of Jahrom is acknowledged. Authors’ contribution Mehdi Bozorgi Mazandarani, Mohammad Kargar, Farshid Kafilzadeh have supervised the study, collected samples, performed the work and written and edited the manuscript. All authors contributed to the article and approved the submitted version. Funding This research received no external funding. Ethical statement This study was ethically approved by the Islamic Azad University, Jahrom Branch, Iran (NO. p-162376730). Prior to participating in the study, every patient or their parent/guardian provided written informed consent and received a brief explanation regarding the study’s purpose. Data availability The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. References Baldelli V, Scaldaferri F, Putignani L, Del Chierico F. The role of Enterobacteriaceae in gut microbiota dysbiosis in inflammatory bowel diseases. Microorganisms. 2021;9(4):697. 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Morris S, Cerceo E. Trends, epidemiology, and management of multi-drug resistant gram-negative bacterial infections in the hospitalized setting. Antibiotics. 2020;9(4):196. Kanaan MHG, Al-Shadeedi SM, Al-Massody AJ, Ghasemian A. Drug resistance and virulence traits of Acinetobacter baumannii from Turkey and chicken raw meat. Comp Immunol Microbiol Infect Dis. 2020;70:101451. Al-Awsi GRL, Al-Hadeithi ZS, Jasim SA, Alkhudhairy MK, Ghasemian A. Virulence traits and plasmid-mediated quinolone resistance among Aggregatibacter actinomycetemcomitans from Iraq: Low rate of highly virulent JP2 genotype. Microb Pathog. 2022;164:105438. Elsayed NY, Awad AMR, Omar MM, Desouki DG. Rapid Simultaneous detection of AmpC and ESBLs among Enterobacteriaceaeusing MastD68C detection set and possible therapeutic options. Egypt J Med Microbiol (EJMM). 2015;24(3). Cheng P, Li F, Liu R, Yang Y, Xiao T, Ishfaq M et al. Prevalence and molecular epidemiology characteristics of carbapenem-resistant Escherichia coli in Heilongjiang Province, China. Infection and drug resistance. 2019:2505–18. Marchaim D, Chopra T, Pogue JM, Perez F, Hujer AM, Rudin S, et al. Outbreak of colistin-resistant, carbapenem-resistant Klebsiella pneumoniae in metropolitan Detroit, Michigan. Antimicrob Agents Chemother. 2011;55(2):593–9. Capone A, Giannella M, Fortini D, Giordano A, Meledandri M, Ballardini M, et al. High rate of colistin resistance among patients with carbapenem-resistant Klebsiella pneumoniae infection accounts for an excess of mortality. Clin Microbiol Infect. 2013;19(1):E23–30. Xiao S, Fu Q, Miao Y, Zhao M, Lu S, Xu J et al. Clinical efficacy and drug resistance of ceftazidime-avibactam in the treatment of Carbapenem-resistant gram-negative bacilli infection. Front Microbiol. 2023;14. Hashemizadeh Z, Hosseinzadeh Z, Azimzadeh N, Motamedifar M. Dissemination pattern of multidrug resistant carbapenemase producing Klebsiella pneumoniae isolates using pulsed-field gel electrophoresis in southwestern Iran. Infect Drug Resist. 2020:921–9. Valizadeh S, Yousefi B, Abdolshahi A, Emadi A, Eslami M. Determination of genetic relationship between environmental Escherichia coli with PFGE and investigation of IS element in blaCTX-M gene of these isolates. Microb Pathog. 2021;159:105154. Zamani K, Emami A, Bazargani A, Moattari A. Phenotypic and molecular characterization of CTX-M extended-spectrum beta-lactamase-producing Escherichia coli isolates in Shiraz, Iran. Rev Soc Bras Med Trop. 2015;48:479–82. Nasrollahian S, Halaji M, Hosseini A, Teimourian M, Armaki MT, Rajabnia M et al. Genetic Diversity, Carbapenem Resistance Genes, and Biofilm Formation in UPEC Isolated from Patients with Catheter-Associated Urinary Tract Infection in North of Iran. International Journal of Clinical Practice. 2022;2022. Walker MM, Roberts JA, Rogers BA, Harris PN, Sime FB. Current and Emerging Treatment Options for Multidrug Resistant Escherichia coli Urosepsis: A Review. Antibiotics. 2022;11(12):1821. Huang Y-S, Tsai W-C, Li J-J, Chen P-Y, Wang J-T, Chen Y-T, et al. Increasing New Delhi metallo-β-lactamase-positive Escherichia coli among carbapenem non-susceptible Enterobacteriaceae in Taiwan during 2016 to 2018. Sci Rep. 2021;11(1):2609. Mahamat OO, Kempf M, Lounnas M, Tidjani A, Hide M, Benavides JA, et al. Epidemiology and prevalence of extended-spectrum β-lactamase-and carbapenemase-producing Enterobacteriaceae in humans, animals and the environment in West and Central Africa. Int J Antimicrob Agents. 2021;57(1):106203. Gaibani P, Lombardo D, Bussini L, Bovo F, Munari B, Giannella M, et al. Epidemiology of meropenem/vaborbactam resistance in KPC-producing Klebsiella pneumoniae causing bloodstream infections in Northern Italy, 2018. Antibiotics. 2021;10(5):536. Boroumand M, Sharifi A, Ghatei MA, Sadrinasab M. Evaluation of biofilm formation and virulence genes and association with antibiotic resistance patterns of uropathogenic Escherichia coli strains in southwestern Iran. Jundishapur J Microbiol. 2021;14(9). Rasoulinasab M, Shahcheraghi F, Feizabadi MM, Nikmanesh B, Hajihasani A, Sabeti S, et al. Distribution of pathogenicity island markers and H-antigen types of Escherichia coli O25b/ST131 isolates from patients with urinary tract infection in Iran. Microb Drug Resist. 2021;27(3):369–82. Nojoomi F, Ghasemian A. The relation of phylogroups, serogroups, virulence factors and resistance pattern of Escherichia coli isolated from children with septicemia. New microbes and new infections. 2019;29:100517. Mokracka J, Koczura R, Jabłońska L, Kaznowski A. Phylogenetic groups, virulence genes and quinolone resistance of integron-bearing Escherichia coli strains isolated from a wastewater treatment plant. Antonie Van Leeuwenhoek. 2011;99:817–24. Lafolie J, Nicolas-Chanoine M-H, Grenouillet F, Hocquet D, Bertrand X. Prevalence of Escherichia coli sequence type 131 and its H30 subclone among E. coli isolates in a French hospital. Int J Antimicrob Agents. 2014;44(5):466–8. Hajihasani A, Ebrahimi-Rad M, Rasoulinasab M, Aslani MM, Shahcheraghi F. The Molecular Characterization and Risk Factors of ST131 and Non-ST131 Escherichia coli in Healthy Fecal Carriers in Tehran, Iran. Jundishapur J Microbiol. 2022;15(5). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4330353","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298300938,"identity":"1bec4e84-bddb-4608-bb97-0b0b5bed7d98","order_by":0,"name":"Mehdi Bozorgi Mazandarani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYFACHgaJxAYI88AHgxo5kAjxWg7OqDhmTJwWRqgWZo4zzEDtBLTotvcevPFwh409v/Txi4cZ29jSNxw/e/DBBwY7Od0G7FrMzpxLtkg8k8Ys2ZdTcLiwTSZ3w5m8ZMMZDMnGZgdwaLmRYyaR2HaYzeAMT8LhmW1suRsO5JhJ8zAcSNyGS8v9N2AtPGAtvG3M6Qbn3xDQcoMHrEXC4Az7gcM8Z5gTDG4QsuVMjjHILwaSPTzgQDaceeONseEMAzx+OX7G8OZPUIjxsD/+AIxKeb7zOYYPPlTYyeHSggR4DMCUAlilAUHlIMD+AEzJNxClehSMglEwCkYQAABzi2SkrubbgQAAAABJRU5ErkJggg==","orcid":"","institution":"Islamic Azad University","correspondingAuthor":true,"prefix":"","firstName":"Mehdi","middleName":"Bozorgi","lastName":"Mazandarani","suffix":""},{"id":298300941,"identity":"11ed2e52-517a-435b-9aca-b8a28287e151","order_by":1,"name":"Mohammad Kargar","email":"","orcid":"","institution":"Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Kargar","suffix":""},{"id":298300944,"identity":"3f1f8791-dd35-425f-8fc7-0953dbe3bbd8","order_by":2,"name":"Farshid Kafilzadeh","email":"","orcid":"","institution":"Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Farshid","middleName":"","lastName":"Kafilzadeh","suffix":""}],"badges":[],"createdAt":"2024-04-26 14:58:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4330353/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4330353/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56276918,"identity":"5a713f59-714c-4993-83f6-9a488d00e8be","added_by":"auto","created_at":"2024-05-10 20:12:22","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1113937,"visible":true,"origin":"","legend":"\u003cp\u003eDendrogram of ESBL producing \u003cem\u003eE. coli\u003c/em\u003e isolates based on PFGE patterns after digestion with enzyme \u003cem\u003eXba\u003c/em\u003eІ with presents the date of isolation, ward, and ST131 clone.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4330353/v1/ad8bd66cf4cd50b8f392e790.jpeg"},{"id":64772277,"identity":"0a7d56d8-7200-4ee2-b0dc-c12eec2a6830","added_by":"auto","created_at":"2024-09-18 15:01:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1898917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4330353/v1/5482c3cb-b433-48c8-a068-e88762f6f22d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Molecular characterization of ESBL and carbapenemase producing Uropathogenic Escherichia coli in hospitalized patients, Tehran, Iran","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cem\u003eEnterobacteriaceae\u003c/em\u003e includes several important human pathogens, such as \u003cem\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, and \u003cem\u003eSalmonella\u003c/em\u003e species (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Uropathogenic \u003cem\u003eE. coli\u003c/em\u003e (UPEC) as a specific pathotype of \u003cem\u003eE. coli\u003c/em\u003e causing urinary tract infections (UTI) encodes various adhesive and secretory virulence factors (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). \u003cem\u003eE. coli\u003c/em\u003e, based on their genetic characteristics classified into various phylogroups, which certain phylogroups such as B2 and D are known to be associated with specific types of pathogenic \u003cem\u003eE. coli\u003c/em\u003e strains such as sequence type 131 (ST131) known clone causing significant extra intestinal infection worldwide (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAntibiotic resistance in \u003cem\u003eE. coli\u003c/em\u003e has recently become a significant concern, due to the ability of these bacteria to acquire and spread resistance genes by various mechanisms such as production of beta-lactamases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Extended-spectrum beta-lactamases producing \u003cem\u003eE. coli\u003c/em\u003e (EP- \u003cem\u003eE.coli\u003c/em\u003e) hydrolyze beta-lactams causes resistant to b-lactams (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCarbapenemase-producing (CP- \u003cem\u003eE. coli\u003c/em\u003e) can hydrolyze carbapenem antibiotics, as a last resort treatment option for multidrug-resistant (MDR) bacterial infections (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The production of carbapenemases by UPEC strains poses a significant public health burden because of limited treatment options (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In addition through biofilm formation, \u003cem\u003eE. coli\u003c/em\u003e can provide the environment for limited antibiotic penetration and exchange of virulence and resistant genes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe ESBL and carbapenemase production indicates a high level of antibiotic resistance, and healthcare providers must rely on alternative antibiotics such as colistin, temocillin, and CAZ/AVI. Herein, we investigated the molecular characteristics, antibiotic resistance and virulence factors in EP- \u003cem\u003eE. coli\u003c/em\u003e causing urinary tract infection in hospital.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample collection\u003c/h2\u003e \u003cp\u003eA total of 300 clinical \u003cem\u003eE. coli\u003c/em\u003e isolates were collected from UTI who have hospitalized in various hospitals in Tehran during January 2019 to December 2020. The \u003cem\u003eE. coli\u003c/em\u003e isolates were identified by CHROM agar medium (HiMedia Co., India), biochemical (catalase, indole, and citrate) tests, and API-20E test strips (BioM\u0026eacute;rieux, France) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAntibiotic susceptibility test\u003c/h2\u003e \u003cp\u003eIn accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines and using the disc diffusion method on Mueller-Hinton agar (Conda, Spain), we performed the antibiotic susceptibility test. The following antibiotics were used in the test: nitrofurantoin (NFT; 300 \u0026micro;g), fosfomycin (FO; 30 \u0026micro;g), gentamycin (GEN; 10 \u0026micro;g), ampicillin (AMP; 10 \u0026micro;g), aztreonam (ATM; 30 \u0026micro;g), trimethoprim/sulfamethoxazole (SXT; 25 \u0026micro;g), ciprofloxacin (CIP; 5 \u0026micro;g), nalidixic acid (NAL; 30 \u0026micro;g), cefotaxime (CTX; 30 \u0026micro;g), ceftazidime (CZA; 30 \u0026micro;g), imipenem (IPM; 10 \u0026micro;g), meropenem (Mpm; 10 \u0026micro;g), ertapenem (ETP; 10 \u0026micro;g), piperacillin/tazobactam (TZP; 100/10 \u0026micro;g), ampicillin/sulbactam (SAM; 10/10 \u0026micro;g), amoxicillin/clavulanic acid (AMC; 20/10 \u0026micro;g), and amikacin (AMK; 30 \u0026micro;g), which all were obtained from Mast Group Ltd., Merseyside, UK. \u003cem\u003eKlebsiella oxytoca\u003c/em\u003e ATCC 13182, and \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922 were used as control strains (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eESBL and carbapenemase production determination\u003c/h2\u003e \u003cp\u003eThe identification of ESBL-producing isolates was determined by E-test (BioM\u0026eacute;rieux\u0026rsquo;) and combination disk test recommended by the CLSI. \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e ATCC 700603 was used as a positive control strain and \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922 as a negative control strain. Identification of carbapenemase-producing isolates was confirmed by the combined disk test, including Mpm\u0026thinsp;\u0026plusmn;\u0026thinsp;EDTA (0.5 M), and Carba NP test, following the CLSI guideline (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAntibiotic resistance in UPEC isolates\u003c/h2\u003e \u003cp\u003eThe minimum inhibitory concentrations (MICs) of Mpm- and carbapenem-resistant \u003cem\u003eE. coli\u003c/em\u003e isolates were determined by E-test method (BioM\u0026eacute;rieux) according to a protocol provided by the manufacturer. Carbapenem-resistant \u003cem\u003eE. coli\u003c/em\u003e isolates were resistant to ETP, IPM, and Mpm, with a MIC\u0026thinsp;\u0026ge;\u0026thinsp;4 \u0026micro;g/ml against Mpm. \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922 strain was considered as the control strain (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Temocillin resistance was determined by disk diffusion method on Mueller\u0026ndash;Hinton agar using temocillin disk (30 \u0026micro;g; Liofilchem, Italy). Temocillin zone diameters were determined, and the results were interpreted as per the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. The MIC of colistin (Sigma Chemical Company, St. Louis, MO, USA) was obtained by the broth microdilution method. \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922 and \u003cem\u003eProteus mirabilis\u003c/em\u003e ATCC 12453 were employed as the control strains. The isolates with MIC\u0026thinsp;\u0026gt;\u0026thinsp;4 were considered as colistin resistant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBiofilm formation assay\u003c/h2\u003e \u003cp\u003eThe biofilm production was quantified using the microtiter plate assay according to prior studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In brief, bacteria cultivated in trypticase soy broth (Merck, USA) containing 1% glucose were incubated at 37\u0026deg;C for 24 h. the ELISA reader was employed for the absorbance determination at the wavelength of 590 nm. The biofilm formation level and OD of isolates were determined as explained before (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAmplification of genes by polymerase chain reaction (PCR)\u003c/h2\u003e \u003cp\u003eDNA was extracted using the boiling method. The PCR test was applied for the amplification of resistant genes (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eVIM\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e \u003csub\u003eIMP\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eKPC\u003c/sub\u003e, and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;48\u003c/sub\u003e), virulence genes (\u003cem\u003epiccsgA\u003c/em\u003e, \u003cem\u003eiutA\u003c/em\u003e, \u003cem\u003eibeA\u003c/em\u003e, \u003cem\u003evat\u003c/em\u003e,\u003cem\u003ehlyA\u003c/em\u003e, \u003cem\u003esat\u003c/em\u003e, \u003cem\u003etraT\u003c/em\u003e, \u003cem\u003ecdt\u003c/em\u003e, \u003cem\u003ecnf1\u003c/em\u003e, \u003cem\u003ekpsMTII\u003c/em\u003e, and \u003cem\u003etcpC\u003c/em\u003e), serogroups (O1, O2, O4, O6, O7, O12, O15, O16, O18, O25, O75, O157 types), and phylogroups (TspE4.C2, \u003cem\u003echuA\u003c/em\u003e and \u003cem\u003eyjaA\u003c/em\u003e) by specific primers. PCR conditions and primers have been described in previous studies (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The PCR products were sequenced, and the DNA sequences of the amplified target sites were aligned and compared with those in the National Centre for Biotechnology Information database using the BLAST.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGenetic relatedness of the isolates\u003c/h2\u003e \u003cp\u003eThe chromosomal DNA was digested by the restriction enzyme \u003cem\u003eXba\u003c/em\u003eI and then subjected to pulse-field gel electrophoresis (PFGE) analysis according to the standard protocols. The DNA of \u003cem\u003eSalmonella\u003c/em\u003e serotype Braenderup strain H8912 was also treated with \u003cem\u003eXba\u003c/em\u003eI and used as a molecular weight standard. The dendrogram was constructed with the aid of Gel Compare II. Isolates with a dice similarity index\u0026thinsp;\u0026ge;\u0026thinsp;80% were considered to be in the same PFGE cluster.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMolecular characterization of sequence type 131 (ST131) clone\u003c/h2\u003e \u003cp\u003eThe ST131 clones were identified by PCR of ST131-specific single nucleotide polymorphisms in \u003cem\u003emdh\u003c/em\u003e and \u003cem\u003egyr\u003c/em\u003eB genes (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The isolates identified as ST131 using PCR were further analyzed by applying multilocus sequence typing \u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe statistical analysis of the data was carried out by the R software version 3.3.3 and interpreted based on the frequency distribution and percentage. Data with the \u003cem\u003ep-\u003c/em\u003evalue less than or equal to 0.05 (95% confidence interval) were regarded as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eAntimicrobial resistance patterns of isolates\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 300 urine samples included in this study, 100 \u003cem\u003eE. coli\u003c/em\u003e isolates were detected. The demographic information and distribution of \u003cem\u003eE. coli\u003c/em\u003e isolates are shown in Table 1. The isolates showed resistance patterns to the following antibiotics: AMP (92%; n=92), CTX (85%; n=85) CZA (74%; n=74), SXT (63%; n=63), ATM (54%; n=54), NAL (51%; n=51), CIP (49%; n=49), SAM (38%; n=38), amoxicillin-clavulanic acid (31%; n=31), TZP (26%; n=26), NFT (21%; n=21), AMK (20%; n=20), gentamicin (18%; n=18), FO (18%; n=18), ETP (12%; n=12), IPM (12%; n=12), and Mpm (%11; n=11). A total of 36/100 (36%) \u003cem\u003eE. coli\u003c/em\u003e isolates were phenotypically ESBL producers. In ESBL-producing isolates, 14/36 (38.8%) and 12/36 (33.3%) were temocillin and carbapenem resistant, respectively, and 11/36 (30.5%) were CP-\u003cem\u003eE.coli\u003c/em\u003e, with a MIC\u0026ge;4 \u0026micro;g/ml against Mpm. In addition, 9/36 (25%) and 6/36 (16.6%) of the isolates were resistant to CAZ/AVI (MIC\u0026ge;128 \u0026micro;g/ml) and colistin (MIC\u0026gt;4 \u0026micro;g/ml), respectively. The \u003cem\u003eE. coli\u003c/em\u003e isolates indicated multiple resistance to antibiotics cephalosporins, sulfonamides, and fluoroquinolones, and 48/100 (48%) of the isolates were classified as MDR. Prior antibiotic consumption and hospitalization were significant risk factors for the isolation of ESBL \u003cem\u003eE. coli\u003c/em\u003e isolates (\u003cem\u003ep\u003c/em\u003e=0.01 and \u003cem\u003ep\u003c/em\u003e=0.02). Noticeably, there was no association between age, gender, different wards and underlying diseases with\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e isolation (\u003cem\u003ep\u003c/em\u003e\u0026gt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Epidemiological characteristics of ESBL and non-ESBL-producing \u003cem\u003eE. coli\u003c/em\u003e \u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable dir=\"rtl\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eNon-ESBL\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e(N=64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eESBL No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e(N=36)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026nbsp;(N=100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e0.907\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e51.5\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=33)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e48.5\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=31)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e52.8 (n=19)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e47.2 (n=17 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e52\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e48\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eGender\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eMale\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eFemale\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e20.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=13)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e34.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=22)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e45.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e13.8\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=5)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e25.0\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=9)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e6.1\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=22)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e18\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e31\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eAge\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;40\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e40-60\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026gt;60\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e0.933\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e15.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=10)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e40.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=26)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e26.5\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=17)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e12.5\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=8)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e4.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=3)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e22.2\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=8)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e38.8\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=14)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e25.0\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=9)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e11.11\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=4)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e2.7 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(n=1)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e18\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e40\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e26\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e12\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eClinical distribution\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eICU\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eNephrology\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eHematology\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eEmergency\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eOther\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e54.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=35)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e45.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=29)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e77.7 (n=28)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e22.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=8)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e63\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eHealthcare occupation\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003ePositive\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eNegative\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e45.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=29)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e54.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=35)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e88.8 (n=32)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e11.1\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e61\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e39\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003ePrior antibiotic use\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003ePositive\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eNegative\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e17.2\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e38.8 (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e26\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eBiofilm formation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.076271186440678%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e0.937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.279661016949152%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e26.5\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=17)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e18.7\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=12)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e12.5\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=8)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e10.9\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=7)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e15.6\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=5)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e6.25\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=4)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e17.1\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.372881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e27.7\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(n=10) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e22.2\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=8)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e13.8\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=5)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e13.8\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=5)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e8.3\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=3)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e0.0\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;(n=0)\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e13.8\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(n=5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.39830508474576%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e27\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e20\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e13\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e12\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e8\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e4\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.872881355932204%\" valign=\"top\"\u003e\n \u003cp dir=\"LTR\"\u003eUnderlying disease\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eDiabetes\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eCancer\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eKidney disease \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eLiver disease\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eHart disease\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eOther\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eNon Underlying disease\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevalence of ESBL and carbapenemase genes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 36 ESBL-producing\u003cem\u003e\u0026nbsp;E. coli\u0026nbsp;\u003c/em\u003eisolates surveyed, 29 (80.5%), 19 (52.7%), and 17 (47.2%) harbored \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX-M\u003c/sub\u003e,\u003csub\u003e\u0026nbsp;\u003c/sub\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e,\u003csub\u003e\u0026nbsp;\u003c/sub\u003eand\u003csub\u003e\u0026nbsp;\u003c/sub\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eSHV\u003c/sub\u003e genes, respectively. All 36 (100%) isolates carried the \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTXM\u003c/sub\u003e gene and was also ESBL producers. Among 11 carbapenemase-producing \u003cem\u003eE. coli\u0026nbsp;\u003c/em\u003eisolates, 54.5% (n=6) and 18% (n=2) harbored \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u0026nbsp;\u003c/sub\u003eand \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u003cem\u003e-\u003c/em\u003e48\u0026nbsp;\u003c/sub\u003egenes, respectively, and 27.2% (n=3) of the isolates harbored both \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u0026nbsp;\u003c/sub\u003eand \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u003cem\u003e-\u003c/em\u003e48\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/sub\u003egenes\u003cem\u003e.\u003c/em\u003e None of the isolates carried \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eKPC\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eIMP\u003c/sub\u003e, and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eVIM\u003c/sub\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003egenes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of isolates by PFGE\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePFGE analysis of 36\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e demonstrated 34 pulsotypes classified into 32 singletons with unique patterns, as well as 2 clusters, each consists of two strains numbered from P1 to P34. Distribution of pulsotypes in different hospital wards and different dates is shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003eResults of biofilm formation \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTotally 26% (26/100) isolates were biofilm producer. As showed in table 1, Biofilm formation has significant association with\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e isolates (\u003cem\u003ep\u003c/em\u003e=0.04). \u0026nbsp;In EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e 14 isolates were biofilm producers which 28.5% (n=4/14) was strong biofilm producers, while 57.1% (n=8/14) and 14.2\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e% (n=2/14) were moderate and weak biofilm producers, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecognition of phylogroups and serogroups\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of the\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e isolates belonged to the phylogenetic groups B2 (52.7%; n=19/36) and D (33.3%; n=12/36), followed by groups B1 (8.3%; n=3/36), A (2.7%; n=1/36), and F (2.7%; n=1/36). Also, serogroup O1 was detected in 36.1% (n=13/36) of the isolates and then in serogroups O25 (22.2%; n=8/36), O75 (13.8%; n= 5/36), O18 (8.3; n=3/36), O15 (5.5; n=2/36), O4 (2.7%; n=1/36), and O16 (2.7%; n=1/36). The serogroup of 8.3% (n=3/36) of the isolates could not be detected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentification of virulence factor genes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e, 97.2% (n=35), 86.1% (n=31), 83.3% (n=30), 80.5% (n=29), 33.3% (n=12), 30.5% (n=11), and 27.7% (n=10) carried \u003cem\u003efimH\u003c/em\u003e,\u003cem\u003e\u0026nbsp;iutA\u003c/em\u003e,\u003cem\u003e\u0026nbsp;fyuA\u003c/em\u003e,\u003cem\u003e\u0026nbsp;inh\u003c/em\u003e,\u003cem\u003e\u0026nbsp;traT\u003c/em\u003e, \u003cem\u003epapП\u003c/em\u003e,\u003cem\u003e\u0026nbsp;\u003c/em\u003eand \u003cem\u003ecsgA\u0026nbsp;\u003c/em\u003egenes, respectively. In addition, 30.5% (n=11), 27.7% (n=10), 25% (n=9), 19.4% (n=7), 16.6% (n=6), 13.8% (n=5), 13.8% (n=5), and 8.33% (n=3) carried \u003cem\u003efimA\u003c/em\u003e,\u003cem\u003e\u0026nbsp;ompT\u003c/em\u003e, \u003cem\u003eusp\u003c/em\u003e,\u003cem\u003e\u0026nbsp;sfa/foc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;hly\u003c/em\u003e,\u003cem\u003e\u0026nbsp;cnf-1\u003c/em\u003e,\u003cem\u003e\u0026nbsp;afa\u003c/em\u003e, and \u003cem\u003eiroN\u003c/em\u003e, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDetection of ST131 clone\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eA total of 19.4% (n=7/36) isolates in\u0026nbsp;EP-\u003cem\u003e\u0026nbsp;E. coli\u003c/em\u003e isolates were identified as ST131. All the \u003cem\u003eisolates\u003c/em\u003e (100%; n=7/7) were \u003cem\u003edetected\u0026nbsp;\u003c/em\u003eas\u0026nbsp;O25b-ST131\u003cem\u003e\u0026nbsp;clone,\u003c/em\u003e which 57.1% (n=4/7) were carbapenemase-producing isolates containing \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX-M\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u0026nbsp;\u003c/sub\u003eand \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA-48\u003c/sub\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003egenes (Table 2). As shown in Table 2, most of the carbapenemase-producing \u003cem\u003eE. coli\u003c/em\u003e isolates were serogroup O1, and three of these isolates containing \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eoxa-48\u0026nbsp;\u003c/sub\u003egenes belonged to O25 (ST131 clone).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Characteristics of Carbapenemase-producing\u003cem\u003e\u0026nbsp;E.coli\u0026nbsp;\u003c/em\u003eisolates\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eESBL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMpm\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIC (\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCTX\u003csub\u003e\u0026nbsp;\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIC (\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCAZ/AVI MIC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eColistin\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTemocillin sensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResistance genes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhyl/Sero\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSequence typing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCX-M/OXA-48/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB1/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCX-M/OXA-48/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/OXA-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCX-M/OXA-48/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/OXA-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB1/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M /NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.823529411764707%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003eCTX-M/NDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.745098039215685%\" valign=\"top\"\u003e\n \u003cp\u003eB2/O16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.803921568627452%\" valign=\"top\"\u003e\n \u003cp\u003eNon-ST131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cem\u003eE. coli\u003c/em\u003e is one of the most causative agent of UTI in the world, and some strains of \u003cem\u003eE. coli\u003c/em\u003e, owing to certain attributes such as high virulence factors and high antibiotic resistance, are rapidly spreading in the globe, like clone ST131 \u003cem\u003eE. coli\u003c/em\u003e (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study found a high prevalence of MDR \u003cem\u003eE. coli\u003c/em\u003e isolates and explored that the antibiotic resistant pattern of these isolates were similar to that reported in other studies in different clinical settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Prior hospitalization and prior antibiotic consumption were significant risk factors for isolation of EP- \u003cem\u003eE. coli\u003c/em\u003e isolates in patients. Several investigations have reported a connection between former antibiotic use, hospitalization, and isolation of MDR strains (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTemocillin and carbapenems are two options for treating EP- \u003cem\u003eE. coli\u003c/em\u003e. Temocillin is stable against ESBLs and AmpC b-lactamase and effective in the treatment of UTI infections (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In our study, temocillin was active against 61.2% of ESBL-producing isolates; therefore, the susceptibility of the isolates to this antibiotic can be considered as an alternative treatment for such intricate infections. Carbapenems are typically used to treat complicated bacterial infections with EP- \u003cem\u003eE. coli\u003c/em\u003e isolates, and the percentage of resistant to these antibiotics varies in different studies and has rapid growth, particularly in developing country, due to excessive use of this class of antibiotics (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Herein, the majority of carbapenem-resistant \u003cem\u003eE. coli\u003c/em\u003e isolates was resistant to most of available antibiotics; therefore, in some cases, colistin is often used for treating the infections caused by these isolates (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The prevalence rate of colistin resistance varies in different countries, which the highest rate (19%) was found in Thailand, and the lowest rate (0.8%) was observed in South Korea (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Colistin resistant in our study, indicating the high use of this antibiotic in the treatment of carbapenem-resistant isolates in Iran because of limited new antibiotic options. CAZ/AVI is recognized as a global new treatment alternative for carbapenem-resistant infections. Although this antibiotic is not admitted to our country as a treatment choice, its resistance rate has been reported. Resistance of CAZ/AVI in carbapenem-resistant isolates has increased to 71.4% in country with CAZ/AVI treatment and current studies reporting the high rate (25%) of CAZ/AVI resistance suggests that the emergence of its resistance is not related to the presence or absence of previous CAZ-AVI treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on PFGE pattern in the present study, similar genotypes were isolated from hospital wards in different times, indicating that some resistance strains have a common origin that can disseminate across hospital wards. Therefore, hospital infection control committee is required to identify the origin of these resistant isolates and employ effective health strategy to decrease the spread of resistant bacteria in the hospital (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). As emphasized in studies, the ICU which ST131 clone with similar pattern were collected is a major ward in disseminating resistant bacterial strains because patients are hospitalized in this ward for a long time, and they can be a source of infection. Hence, hospital infection control committee have to pay more attention to the control of dissemination of infection in hospitals via the patients, foods, water, doctors, staff, and bed by surveillance and finding the source of infection (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe prevalence of ESBL and carbapenemase genes can vary depending on geographical locations, healthcare settings, and the population being studied. ESBL enzymes, which hydrolyze the cephalosporins (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and cefepime) and monobactams (aztreonam), are becoming a major challenge for treatment of pathogenic bacteria. However, the same as a previous study conducted in our country, the prevalence of CTX-M is high and noticeable (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Carbapenemase genes are responsible for encoding enzymes that can break down and inactivate carbapenem antibiotics, which are considered last-resort antibiotics for treating severe bacterial infections. The prevalence of carbapenemase genes among carbapenem-resistant bacteria is influenced by factors such as antibiotic use, infection control practices, and the dissemination of resistant strains (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In some parts of the world, the prevalence of carbapenemase genes can be relatively high, particularly in countries with high rates of antibiotic use and inadequate infection control measures, for instance, certain countries in Southeast Asia, the Middle East, and regions of Europe have reported high rates of bacteria producing carbapenemase (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). It is worth mentioning that surveillance data on the prevalence of carbapenemase genes can vary over time and across different studies (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Local and regional surveillance programs, as well as molecular testing methods, are crucial for monitoring the prevalence and spread of carbapenemase genes.\u003c/p\u003e \u003cp\u003eBased on available evidence, the global prevalence rate of biofilm formation is different, ranging between 56% and 100%. This observation shows that various factors, including different geographical areas, low-level hygiene, varying methods, can affect the biofilm formation. In our study, the same as other survey (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), there was an association between biofilm formation and antibiotic resistance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04), which could arise from the antibiotic misuse and its administration without prescription in our country. In our study, similar to Boroumand et al.\u0026rsquo;s study (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and contrary to Rasoulinasab et al.\u0026rsquo;s study (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), \u003cem\u003efimH\u003c/em\u003e and \u003cem\u003eiutA\u003c/em\u003e were the predominant and \u003cem\u003eiroN\u003c/em\u003e was the lowest virulence factors. This variation in the prevalence rate of genes is possibly due to the different source of the samples.\u003c/p\u003e \u003cp\u003eIn this study, the B2 phylogroup was the predominant phylogroup. It has been reported that the prevalence rate of phylogroups is different in the phylogroup pattern of \u003cem\u003eE. coli\u003c/em\u003e isolates, which could be ascribed to the source of isolates (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, the high prevalence rate of phylogroup B2 in our study was noticeable.\u003c/p\u003e \u003cp\u003eOne of the important sequence types with high antibiotic resistant in EP- \u003cem\u003eE. coli\u003c/em\u003e isolates is ST131clone, as the causative agent of UTI. There are different reported rates of this clone in the world and it is also varied in different parts of our country which is probably due to varying times of studies conducted, geographical locations, and sample types (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Isolation of carbapenem-resistant isolate ST131 in this study is a warning for more dissemination of carbapenem resistance genes in our country and in the world.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings demonstrated a high prevalence of virulence genes and antibiotic resistance in \u003cem\u003eE. coli\u003c/em\u003e which has been transferred between hospitalized patients. Hence, surveillance is needed to control the spread of MDR strains particularly in special wards. In addition, in the present study, CP- \u003cem\u003eE. coli\u003c/em\u003e could carry \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;48\u003c/sub\u003e genes belonging to ST131 O25/B2 with high antibiotic resistant, which remains a risk for treatment and dissemination of resistant genes in hospital. Therefore, rapid molecular detection of high-risk clones can be helpful in limiting the dissemination of such strains.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe equipment support of this study by the\u0026nbsp;Islamic Azad University of Jahrom\u0026nbsp;is acknowledged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMehdi Bozorgi Mazandarani, Mohammad Kargar, Farshid Kafilzadeh\u0026nbsp;have supervised the study, collected samples, performed the work and written and edited the manuscript.\u0026nbsp;All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was ethically approved by the Islamic Azad University, Jahrom Branch, Iran (NO. p-162376730). Prior to participating in the study, every patient or their parent/guardian provided written informed consent and received a brief explanation regarding the study\u0026rsquo;s purpose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaldelli V, Scaldaferri F, Putignani L, Del Chierico F. The role of Enterobacteriaceae in gut microbiota dysbiosis in inflammatory bowel diseases. Microorganisms. 2021;9(4):697.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanabe RH, Dias RC, Orsi H, de Lira DR, Vieira MA, Dos Santos LF, et al. Characterization of uropathogenic Escherichia coli reveals hybrid isolates of uropathogenic and diarrheagenic (UPEC/DEC) E. coli. 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Jundishapur J Microbiol. 2021;14(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasoulinasab M, Shahcheraghi F, Feizabadi MM, Nikmanesh B, Hajihasani A, Sabeti S, et al. Distribution of pathogenicity island markers and H-antigen types of Escherichia coli O25b/ST131 isolates from patients with urinary tract infection in Iran. Microb Drug Resist. 2021;27(3):369\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNojoomi F, Ghasemian A. The relation of phylogroups, serogroups, virulence factors and resistance pattern of Escherichia coli isolated from children with septicemia. New microbes and new infections. 2019;29:100517.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMokracka J, Koczura R, Jabłońska L, Kaznowski A. Phylogenetic groups, virulence genes and quinolone resistance of integron-bearing Escherichia coli strains isolated from a wastewater treatment plant. Antonie Van Leeuwenhoek. 2011;99:817\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafolie J, Nicolas-Chanoine M-H, Grenouillet F, Hocquet D, Bertrand X. Prevalence of Escherichia coli sequence type 131 and its H30 subclone among E. coli isolates in a French hospital. Int J Antimicrob Agents. 2014;44(5):466\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajihasani A, Ebrahimi-Rad M, Rasoulinasab M, Aslani MM, Shahcheraghi F. The Molecular Characterization and Risk Factors of ST131 and Non-ST131 Escherichia coli in Healthy Fecal Carriers in Tehran, Iran. Jundishapur J Microbiol. 2022;15(5).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Uropathogenic Escherichia coli, virulence typing, carbapenemase, serogrouping, phylogroups","lastPublishedDoi":"10.21203/rs.3.rs-4330353/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4330353/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUropathogenic \u003cem\u003eEscherichia coli\u003c/em\u003e (UPEC) with antibiotic resistance and virulence factors can cause urinary tract infections (UTIs). The aim of this survey was to evaluate the genetic characteristic of extended-spectrum beta-lactamases (ESBLs) and carbapenemase producing UPEC (CP-UPEC) isolates.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this cross-sectional study, 300 UPEC isolates were collected from the urine samples of patients hospitalized between January 2019 and December 2020. The antibiotic susceptibility of the isolates was evaluated by disk diffusion method. The minimum inhibitory concentration (MIC) of meropenem and CAZ/AVI were determined by E-test, and that of colistin was determined by micro broth dilution method. Biofilm formation was assessed by microtiter plate assay. Antibiotic-resistant genes, virulence factors, phylogroups, and serogroups were detected by polymerase chain reaction (PCR) technique. The relationship between the isolates was evaluated by pulsed-field gel electrophoresis (PFGE) typing. Sequence type 131 (ST131) isolates were identified by PCR and confirmed by multilocus sequence typing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 100 isolates were collected from UTI patients which 36% (n\u0026thinsp;=\u0026thinsp;36) of isolates were ESBL producing \u003cem\u003eE. coli\u003c/em\u003e (EP-\u003cem\u003eE.coli\u003c/em\u003e). Among 36 EP-\u003cem\u003eE.coli\u003c/em\u003e isolates, 14 (38.8%), 33.3% (n\u0026thinsp;=\u0026thinsp;12), 25% (n\u0026thinsp;=\u0026thinsp;9), and 16.6% (n\u0026thinsp;=\u0026thinsp;6) were temocillin, carbapenem, CAZ/AVI, and colistin resistant. 33.5% (n\u0026thinsp;=\u0026thinsp;11/36) of EP-\u003cem\u003eE.coli\u003c/em\u003e were carbapnememase producing \u003cem\u003eE.coli\u003c/em\u003e (CP-\u003cem\u003eE.coli\u003c/em\u003e). Also, of these 36 isolates, 29 (80.5%) harbored \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eCTX\u0026minus;M\u003c/sub\u003e gene and 7 (19.4%) were detected to be ST131. In addition, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;48\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u003c/sub\u003e carbapenemase genes existed in CP-\u003cem\u003eE.coli\u003c/em\u003e isolates. Virulence genes were mostly \u003cem\u003efimH\u003c/em\u003e (97.2%; n\u0026thinsp;=\u0026thinsp;35), \u003cem\u003eiutA\u003c/em\u003e (86.1%; n\u0026thinsp;=\u0026thinsp;31), and \u003cem\u003efuA\u003c/em\u003e (80.5%; n\u0026thinsp;=\u0026thinsp;29). O1 (36.1%), and O25 (22.2%) were predominant serogroups. Phylogroup typing showed that 52.7% of isolates belonged to B2 phylogroup, and PFGE typing showed 32 singletons and 2 clusters.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur findings revealed the high prevalence of antibiotic resistant in EP-\u003cem\u003eE.coli\u003c/em\u003e isolates, likely due to the excess clinical use of antibiotics. In addition CP-\u003cem\u003eE.coli\u003c/em\u003e isolates belonging to ST131-O25-B2 could carry \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u003c/sub\u003e and \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;48\u003c/sub\u003e genes and transferred between different ward of our hospital, since there are limited options to treat the infection caused by these isolates, surveillance is needed to control the spread of such multidrug-resistant strains of \u003cem\u003eE. coli\u003c/em\u003e.\u003c/p\u003e","manuscriptTitle":"Molecular characterization of ESBL and carbapenemase producing Uropathogenic Escherichia coli in hospitalized patients, Tehran, Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-10 20:10:26","doi":"10.21203/rs.3.rs-4330353/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8582924-10ed-4b33-b152-cbaa13d58f02","owner":[],"postedDate":"May 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-18T14:53:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-10 20:10:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4330353","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4330353","identity":"rs-4330353","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}