Prosthetic Stent Graft Infection Caused by Aerococcus urinae: A Case Report and Literature Review.

Aerococcus urinae, a gram-positive, catalase-negative coccus, has emerged as a notable pathogen in clinical microbiology. It is traditionally associated with urinary tract infections in elderly males with underlying urologic conditions. Recently, A. urinae has been implicated in severe invasive infections outside the genitourinary tract including infective endocarditis, vertebral osteomyelitis, peritonitis, lymphadenitis, and discitis. We present the case of 84-year-old male with a history of aortic graft replacement who presented with five days of fever and fatigue. Blood and urine cultures grew gram-positive cocci, identified as A. urinae. Thoracoabdominal contrast-enhanced CT revealed a slightly increased soft tissue shadowing around the prosthetic stent in the ascending aorta, indicating a possible aortic stent-graft infection. Gallium-67 scintigraphy demonstrated inflammation around the prosthetic stent in the ascending aorta consistent with an aortic stent-graft infection. The patient and family opted for conservative treatment and despite a six-week inpatient course of ampicillin, followed by oral amoxicillin, the patient died one week after discharge. This is the first published case of A. urinae causing an aortic stent-graft infection. Clinicians should remain cognizant of the disseminated source of infection in cases of A. urinae bacteremia.

Case of Emphysematous Cholangitis Caused by Gas-producing Bacteria with an Initial Literature Review.

Emphysematous cholecystitis has a poor prognosis and necessitates prompt surgery or drainage. Emphysematous cholangitis (EC) is believed to have a similar clinical course, but reports are limited. We herein report the case of a 79-year-old woman who presented with epigastric pain and was diagnosed with EC. Rapid deterioration occurred after admission, requiring intensive and prolonged intravenous antibiotic therapy, despite immediate drainage and antibiotic therapy. We reviewed the background, causative organisms, treatment, and outcomes of EC through a literature search. Our findings provide insights into its similarities to emphysematous cholecystitis, emphasizing the need for expeditious drainage and anaerobic bacterial coverage during antibiotic therapy.

Intermittent Versus Daily Trimethoprim/Sulfamethoxazole Regimens for Pneumocystis Pneumonia Prophylaxis: A Systematic Review and Meta-analysis.

Background: In immunocompromised individuals, trimethoprim/sulfamethoxazole (TMP/SMX) for Pneumocystis pneumonia (PCP) prophylaxis has adverse events, and the optimal dosage is unclear. The objective of this study was to assess efficacy and safety of intermittent versus daily TMP/SMX for PCP prophylaxis. Methods: This systematic review included randomized controlled trials (RCTs) indexed in the Cochrane Central Register of Controlled Trials, PubMed, Ichushi, or Embase databases, published from database inception to September 2023. The inclusion criteria were adults taking intermittent or daily TMP/SMX for PCP prophylaxis. Risk of bias was assessed using the Cochrane risk-of-bias tool. The primary outcomes were PCP incidence, PCP-related mortality, and adverse events requiring temporary or permanent TMP/SMX discontinuation. Results: Four RCTs (N = 2808 patients) were included. PCP incidence did not differ significantly between the intermittent and daily regimen groups (risk ratio [RR], 1.17 [95% confidence interval {CI}, .89-1.53]; certainty: very low). There was no PCP-related mortality in the 3 RCTs reporting its outcome. Compared with the daily regimen group, the intermittent regimen group experienced significantly fewer adverse events requiring temporary or permanent TMP/SMX discontinuation (RR, 0.51 [95% CI, .42-.61]; certainty: low). Conclusions: This systematic review and meta-analysis suggests that intermittent TMP/SMX regimens for PCP prophylaxis may be more tolerable than daily regimens and may have similar efficacy. Further RCTs are needed to apply this to current practice. Clinical Trials Registration. PROSPERO (CRD42022359102).

Retrospective study on penicillin allergy delabeling and evaluation of an antibiotic allergy assessment tool.

BACKGROUND: It has been reported that 95 % of patients labeled as penicillin-allergic may be mislabeled. However, the process of delabeling has not advanced due to a shortage of allergy specialists capable of conducting accurate assessments. To address this issue, The Antibiotics Allergy Assessment Tool (AAAT) has been proposed as a tool to evaluate patients who can be delabeled by non-specialists. OBJECTIVE: This study aims to identify patients who can be delabeled and to evaluate patients who are likely to be delabeled using AAAT. METHODS: Patients admitted to the hospital between January 1, 2017, and December 31, 2021, with documented penicillin allergy labels were included in the study. Patients who demonstrated tolerance to labeled antibiotics or were labeled without explicit allergy declarations were defined as delabeling. Subsequently, patients who did not meet the criteria for delabeling were evaluated for their potential to be delabeled using the AAAT, retrospectively. RESULTS: 530 patients were selected, of which 62 (11.7 %) were delabeled. The AAAT evaluation of the remaining patients indicated that at least an additional 137 (25.8 %) patients could potentially be delabeled. CONCLUSION: The use of AAAT demonstrated the potential to delabel approximately third as many patients without the need for specialist evaluation. To promote broader delabeling efforts in the future, prospective studies should investigate the safety and effectiveness of evaluation tools such as the AAAT.

Adverse Events Comparison of Double Beta-Lactam Combinations for Bloodstream Infections: Ampicillin plus Ceftriaxone and Ampicillin/Cloxacillin.

In Japan, only ampicillin/cloxacillin (ABPC/MCIPC) is available as an anti-staphylococcal penicillin-based treatment for Staphylococcus aureus bacteremia. However, the incidence of adverse events associated with double beta-lactam administration remains unknown. Therefore, we investigated the adverse events of double beta-lactam administration in patients with bacteremia. Adult patients (≥18 years) with bacteremia treated with ABPC, ABPC + ceftriaxone (CTRX), or ABPC/MCIPC were retrospectively analyzed. The primary outcome of this study was the incidence of adverse events such as acute kidney injury, liver dysfunction, and myelosuppression. Chi-square tests and t-tests were used for bivariate analysis. Propensity score (PS) matching was conducted to adjust for confounding factors. We included 277 ABPC-, 57 ABPC + CTRX-, and 43 ABPC/MCIPC-treated patients. Significant differences were noted in age, number of male patients, proportion of patients with qSOFA score ≥2, incidence of chronic kidney disease, treatment duration, mechanical ventilation use, vasopressor use, and proportion of patients with acute kidney injury (AKI) KDIGO grade ≥2. Further, a significant difference was observed between ABPC and ABPC/MCIPC, with a hazard ratio of 1.83 in AKI. In the PS-matched cohort, AKI incidence associated with ABPC/MCIPC was significantly higher than that associated with ABPC. ABPC + CTRX may be safe, whereas ABPC/MCIPC presents a higher risk of AKI and may not be suitable.

Cytomegalovirus Infection of the Gastrointestinal Tract in Patients on Hemodialysis: A Case Report and Literature Review.

Cytomegalovirus (CMV) infection is widespread in immunocompromised people, and several cases of CMV infections of the gastrointestinal (GI) tract have been reported in these individuals. We present a case of an immunocompetent patient on hemodialysis (HD) who developed CMV colitis. We also conducted a review of the literature on CMV GI tract infections among patients with chronic kidney disease undergoing dialysis. A 46-year-old man with a history of end-stage renal disease and undergoing HD developed severe diarrhea and hematochezia. A colonoscopy revealed ulcers, and CMV infection was identified in the biopsy sample. We successfully treated the patient with valganciclovir for 2 months. Our review of the literature yielded 21 articles and 24 cases of CMV GI tract infection in patients undergoing dialysis, including the current case. Hematochezia and diarrhea were purported to serve as indicators of CMV GI tract infection among patients on dialysis. Thus, clinicians should suspect CMV infection of the GI tract in dialysis patients, who experience unexplained bloody diarrhea, and promptly perform a GI endoscopy and biopsy.

Collateral pathways arising from internal jugular venous occlusion in Lemierre's syndrome.

The use of anticoagulants in Lemierre's syndrome is not well-defined, lacking clear evidence for their efficacy. This report describes a patient with complete occlusion of the internal jugular vein by a thrombus who did not develop expected complications due to the formation of collateral venous channels.

Syphilis and nephrotic syndrome: A case report and literature review.

A 31-year-old woman who had unprotected sexual intercourse with multiple partners presented to our hospital with bilateral leg edema, weight gain, and eyelid edema. One month before her visit, she had a fever of 38.0 â„ƒ for 2 days, and 1 week before her visit, she experienced fatigue. The presence of hypoalbuminemia, proteinuria, and leg edema raised the suspicion of nephrotic syndrome along with syphilis. She was treated with doxycycline for secondary nephrotic syndrome caused by secondary syphilis. Secondary syphilis is a well-known but rare cause of secondary nephrotic syndrome, and the occurrence rate, risk factors, and timing of occurrence are unknown. Therefore, we have supplemented this case report with a concise review of the relevant literature that delineates the use of appropriate antibiotic therapy in the management of secondary nephrotic syndrome derived from secondary syphilis.

Emerging Meningococcal B Meningitis in Japan: A Case Report of a 50-Year-Old Japanese Man with Diabetes.

BACKGROUND Meningococcal meningitis is rare in Japan; however, when outbreaks do occur, they predominantly involve domestically infected cases rather than those contracted overseas. CASE REPORT A Japanese man with diabetes in his 50s experienced fever and loss of consciousness, with no history of international travel. In our hospital, gram-negative diplococci were detected in the cerebrospinal fluid (CSF) of the patient by Gram staining, although the rapid agglutination test and cultures of blood and CSF were negative. Multiplex polymerase-chain reaction (PCR) testing returned positive results for meningococcus and parechovirus. Brain MRI revealed a finding of meningitis, but there were no indications of encephalitis. To determine the serotype and genotype, we sent the sample to the National Institute of Infectious Diseases, which identified the serogroup and sequence type (ST) as type B and 2057, respectively. Despite the unknown antimicrobial susceptibility, the patient responded well to empirical treatment with ceftriaxone at 2 g every 12 h, and was discharged with remaining symptoms of dizziness, headache, difficulty hearing in the left ear, and tinnitus in the left ear. CONCLUSIONS In Japan, vaccines covering serogroups A, C, and W/Y are available but not routinely administered. According to epidemiological surveillance reports, serogroup B is the second most common cause of meningococcal meningitis in Japan, yet there is no corresponding vaccine available in the country. This case has prompted a review of the epidemiology of meningococcus in Japan, encompassing strategies for vaccination and hospital infection control to prevent droplet transmission, which includes post-exposure prophylaxis when no prior measures have been implemented.

Postoperative Course and Supportive Care in Very Elderly Cecum Cancer Patients.

In developed countries like Japan, the size of the older population is rapidly increasing. Malignant neoplasms rank as the leading cause of death among the geriatric population of Japan, emphasizing the rising demand for cancer care in this demographic. Older patients, besides facing physical and cognitive challenges, are also affected by their social environment, necessitating tailored interventions. Few case reports have detailed the progress of cancer treatment in nonagenarian patients. This study presents the progress of two very old patients with cancer. The first case, a 95-year-old female with chronic constipation underwent emergency surgery for a cecal tumor. Despite initial improvements, her mobility declined after surgery, leading to institutionalization. Recurrent hospitalizations ensued with complications culminating in her death approximately 20 months after surgery. In the second case, a 94-year-old male, initially declining aggressive treatment for a suspected ileocecal malignancy, later opted for supportive care. Despite stable conditions, he eventually died at home after experiencing progressive weakness, which was approximately 20 months after the initial diagnosis. These cases shed light on the management of elderly patients with ileocecal cancer, illustrating the divergent trajectories between surgical intervention and supportive care. The tumor did not recur in the patient who underwent surgery; however, the independence in performing daily living activities declined significantly. In the case managed with the best-supportive care, progression was slow; however, severe anemia became a concern toward the end of life.

Correction: Ishikawa et al. Systematic Review of Beta-Lactam vs. Beta-Lactam plus Aminoglycoside Combination Therapy in Neutropenic Cancer Patients. Cancers 2024, 16, 1934.

There was an error in the original publication [...].

Systematic Review of Beta-Lactam vs. Beta-Lactam plus Aminoglycoside Combination Therapy in Neutropenic Cancer Patients.

We performed a systematic review of studies that compared beta-lactams vs. beta-lactams plus aminoglycosides for the treatment of febrile neutropenia in cancer patients. METHOD: We searched CENTRAL, MEDLINE, and Embase for studies published up to October 2023, and randomized controlled trials (RCTs) that compared anti-Pseudomonas aeruginosa beta-lactam monotherapy with any combination of an anti-Pseudomonas aeruginosa beta-lactam and an aminoglycoside were included. RESULT: The all-cause mortality rate of combination therapy showed no significant differences compared with that of monotherapy (RR 0.99, 95% CI 0.84 to 1.16, high certainty of evidence). Infection-related mortality rates showed that combination therapy had a small positive impact compared with the intervention with monotherapy (RR 0.83, 95% CI 0.66 to 1.05, high certainty of evidence). Regarding treatment failure, combination therapy showed no significant differences compared with monotherapy (RR 0.99, 95% CI 0.94 to 1.03, low certainty of evidence). In the sensitivity analysis, the treatment failure data published between 2010 and 2019 showed better outcomes in the same beta-lactam group (RR 1.10 [95% CI, 1.01-1.19]). Renal failure was more frequent with combination therapy of any daily dosing regimen (RR 0.46, 95% CI 0.36 to 0.60, high certainty of evidence). CONCLUSION: We found combining aminoglycosides with a narrow-spectrum beta-lactam did not spare the use of broad-spectrum antibiotics. Few studies included antibiotic-resistant bacteria and a detailed investigation of aminoglycoside serum levels, and studies that combined the same beta-lactams showed only a minimal impact with the combination therapy. In the future, studies that include the profile of antibiotic-resistant bacteria and the monitoring of serum aminoglycoside levels will be required.

Invasive pneumococcal serotype 3 infection following pneumococcal vaccination in a hematopoietic stem cell transplant patient: A case report.

Given the high mortality rate of invasive pneumococcal disease (IPD) in hematopoietic stem cell transplant (HSCT) recipients, vaccination is recommended. These recipients respond to most vaccines; however, their immune response is typically weaker during the first months or years after transplantation, compared with that of healthy individuals. Here, we report a case of IPD with serotype 3 pneumonia and empyema in an HSCT recipient who had received three doses of the 13-valent pneumococcal conjugate vaccine (PCV) and one dose of the 23-valent pneumococcal polysaccharide vaccine; furthermore, the recipient had no relapse, graft-versus-host disease, or use of immunosuppressive agents after allogeneic HSCT for acute myeloid leukemia. Moreover, we discussed the characteristics of serotype 3 Streptococcus pneumoniae, a case series of breakthrough infections with S. pneumoniae in HSCT recipients who received pneumococcal vaccines, and the potential implications for the upcoming PCV15 and PCV20 vaccines for serotype 3.

A Rare Cause of Empyema and Bacteremia Due to Shewanella Species in Alcoholic Cirrhosis Patients: A Case Report and Comprehensive Review of Literature.

BACKGROUND Shewanella spp. are gram-negative facultative anaerobic, oxidase-positive, motile bacilli that are ubiquitous but commonly occur in seawater and can cause opportunistic infection. Reports on the risk factors for Shewanella infection, its severity, antibiotic susceptibility, and prognosis are limited. This report is of a 78-year-old man with alcoholic cirrhosis presenting with bacteremia and empyema due to infection with Shewanella spp. CASE REPORT A 78-year-old man with alcoholic cirrhosis (Child-Pugh B) presented to our emergency room with a high fever. He had eaten raw fish one week prior to admission. Chest computed tomography showed a right unilateral pleural effusion, and he was hospitalized with suspected empyema. Shewanella spp. was detected in the pleural effusion and blood cultures. We initiated piperacillin/tazobactam and vancomycin empirically and switched to ceftriaxone; the effusion was successfully treated using antibiotics and pleural drainage. However, on hospitalization day 53, the patient died of aspiration pneumonia. In our literature review, we extracted 125 reported cases (including our case) and found that men were disproportionately affected (81%); median age was 61.6 (56-75) years; underlying diseases included hepatobiliary disease (33%), malignancy (25%), and cardiac disease (24%); Shewanella spp. infection sites were skin and soft tissue (35%), respiratory system (18%), and hepatobiliary system (11%); and management included antibiotics (100%), drainage (16%), and debridement (16%). The survival rate was 74% with antibiotics alone. CONCLUSIONS Our case highlights that clinicians should recognize Shewanella spp. as a cause of empyema and bacteremia in patients with liver cirrhosis, and that microbiological diagnosis with antibiotic sensitivity testing and treatment should be undertaken urgently to prevent fatal sepsis.

Anaerobic gram-negative rod bacteremia as a marker of gastrointestinal cancer in Japanese patients: a single-center retrospective study.

BACKGROUND: Gram-negative rod (GNR) bacteremia has been suggested as a clinical marker of occult cancer; however, no studies are available in this regard in the Japanese population. Here, we investigated the risk factors for gastrointestinal cancer with GNR bacteremia. METHODS: Patients with GNR bacteremia admitted to St. Luke's International Hospital between January 2011 and July 2021 were included. The clinical data of patients with and without cancer, 1 year before and after GNR bacteremia diagnosis, were compared. Univariate analysis was performed using χ2 and Fisher's exact tests for categorical variables and the Mann-Whitney U test for continuous variables, while multivariable analysis was performed using logistic regression analysis, and a P of <0.05 was considered statistically significant. RESULTS: Of 2,296 GNR bacteremia-positive patients, 96 were associated with gastrointestinal cancer, and univariate analysis showed significant differences between the gastrointestinal cancer and comparison groups in terms of mean body mass index (BMI; 20.5 vs. 21.8 kg/m2), Enterobacterales detection (64.6% vs. 81.3%), and anaerobic GNR detection (24.0% vs. 8.5%). Thirty-five (36%) and 61 (64%) patients had upper and lower gastrointestinal cancer, respectively. There were 23 patients with anaerobic GNR bacteremia related to 24 strains (upper and lower gastrointestinal cancer, 5 and 18 cases, respectively). Multivariate analysis identified anaerobic GNR [odds ratio, 3.440; 95% confidence interval (CI): 2.085-5.675, P<0.001] as a significant risk factor for cancer. CONCLUSIONS: Anaerobic GNR in blood cultures may be a risk factor for gastrointestinal cancer. Therefore, it is necessary consider cancer workup, such as endoscopy, for patients with anaerobic GNR bacteremia.

Bilateral Sialadenitis as an Uncommon Initial Manifestation of Infectious Mononucleosis: A Case Report.

Sialadenitis has rarely been reported in patients with infectious mononucleosis (IM). Our patient was a 22-year-old man who presented with bilateral swelling of the parotid and submandibular glands, a fever, malaise, and splenomegaly. Laboratory tests revealed an increased percentage of atypical lymphocytes in the leukocyte fraction. Serological testing for antibodies against Epstein-Barr virus (EBV) revealed an acute infection pattern. The patient was diagnosed with sialadenitis associated with IM caused by EBV infection. With symptomatic treatment, the salivary gland swelling completely resolved within a week. This case suggests that EBV-induced IM should be included in the differential diagnosis of diffuse sialadenitis with elevated atypical lymphocyte counts.

Corynebacterium bacteremia in patients with hematologic disorders: a case series and systematic literature review.

Corynebacterium is generally considered a contaminant in clinical practice. However, it may cause bacteremia in patients with hematologic disorders, and factors that contribute to its mortality are unclear. A case series and systematic literature review identified 96 cases of Corynebacterium bacteremia inhematologic disorderpatients. The median age was 50.5 years (range: 2-93 years), with 79 (82%) patients 18 years or older, and 64 (67%) patients male. Most cases involved hematologic malignancies, and neutropenia was observed in approximately 75% cases. The most common sites of infection/symptoms were skin and soft tissue, respiratory, and catheter-related bloodstream infection. The infection-related mortality was 23%, and univariate analysis showed that age, respiratory infection/symptoms, and source control were significantly associated with infection-related mortality. Multivariate analysis indicates that infection-related mortality was significantly reduced by source control (OR: 0.24, 95% CI: 0.06-0.97, p = 0.046). Therefore, when Corynebacterium infections are suspected, early source control should be considered.

Recurrent Bacillus subtilis Var. Natto Bacteremia and Review of the Literature on Bacillus subtilis: The First Case Report.

BACKGROUND Fermented foods, such as yogurt, are often considered healthy; however, there have been numerous reported cases of bacteremia associated with their consumption. In this report, we present a case of Bacillus subtilis var. natto (B. subtilis var. natto) bacteremia related to the consumption of natto, a traditional Japanese food made from fermented soybeans. We also conducted a literature review on B. subtilis bacteremia. CASE REPORT We report the case of a 41-year-old woman who presented with fever, had a medical history of congenital liver fibrosis, and experienced recurrent B. subtilis var. natto bacteremia along with acute cholangitis. Although she discontinued eating natto, she developed pyogenic thrombophlebitis due to B. subtilis var. natto. We successfully treated her with meropenem and an anti-coagulant. To investigate the management and prognosis of B. subtilis var. natto bacteremia, we conducted a literature review of B. subtilis intra-abdominal infection. We identified 17 papers describing 30 cases of B. subtilis intra-abdominal infection, 4 cases of which were caused by B. subtilis var. natto; the median age of the patients was 71 years (range, 15-96 years), 14 patients (47%) were female, and 3 patients (10%) died. From our findings, our case was the only one of recurrent B. subtilis var. natto infection. Even after patients discontinue eating natto, they should be carefully monitored. CONCLUSIONS Due to advancements in PCR identification techniques, case reports of infections caused by B. subtilis var. natto are increasing.

Empyema necessitans caused by methicillin-resistant Staphylococcus aureus: a case report and literature review.

BACKGROUND: Empyema necessitans (EN) is a rare condition characterized by pleural infection with pus spreading into adjacent soft tissues. Although Mycobacterium tuberculosis and Actinomyces israelii are common causative agents, methicillin-resistant Staphylococcus aureus (MRSA) is relatively rare, but it is associated with high mortality in empyema cases. We aimed to report a unique case of EN caused by MRSA and present a literature review to better understand this rare condition. CASE PRESENTATION: A 69-year-old man with a history of right ureteral stone presented with fever and left anterior thoracic pain. A physical examination revealed redness and swelling in the left thoracic region. Imaging studies confirmed EN with fluid accumulation around the sternocostal joint of the left first rib. MRSA was identified from blood and pleural fluid cultures. The patient received antimicrobial therapy, and a chest tube was inserted for drainage. Despite initial improvement, vertebral osteomyelitis was diagnosed on day 17. The antimicrobials were subsequently terminated after 6 weeks, but vertebral osteomyelitis recurred, and treatment was resumed and completed on day 215. CONCLUSION: EN caused by MRSA is rare, and the literature review revealed 14 cases from human sources. Positive blood cultures were observed in 40% of cases, and metastatic infections were present in 30% of cases. Osteomyelitis was the most common type of metastatic lesion. All the patients underwent drainage. Patients with MRSA-associated EN frequently develop disseminated lesions and should therefore be carefully examined. Moreover, appropriate treatment with antibiotics and drainage is necessary for a good prognosis. Although the prognosis appeared to be favorable in our review, publication bias and treatment challenges for metastatic infections should be considered.

Clinical Features, Genome Epidemiology, and Antimicrobial Resistance Profiles of Aeromonas spp. Causing Human Infections: A Multicenter Prospective Cohort Study.

Background: The genus Aeromonas is increasingly implicated in human infections, but knowledge of its clinical characteristics and antimicrobial resistance profiles has been limited owing to its complex taxonomy. Methods: We conducted a multicenter prospective cohort study of patients with Aeromonas infections at hospitals across Japan. Patients were eligible for inclusion if they had an Aeromonas spp. strain in a clinical culture and were considered infected at the culture site. Clinical data were collected, and isolates underwent susceptibility testing and whole-genome sequencing. Results: A total of 144 patients were included. Hepatobiliary infection accounted for a majority of infections (73% [105 of 144]), which mostly occurred in elderly patients with comorbid conditions, including hepatobiliary complications. The all-cause 30-day mortality rate was 10.0% (95% confidence interval, 4.9%-14.8%). By whole-genome sequencing, 141 strains (98%) belonged to 4 Aeromonas species-A caviae, A hydrophila, A veronii, and A dhakensis-with significant intraspecies diversity. A caviae was predominant in all infection sites except skin and soft tissue, for which A hydrophila was the prevailing species. The genes encoding chromosomally mediated class B, C, and D ß-lactamases were harbored by 92%-100% of the isolates in a species-specific manner, but they often lacked association with resistance phenotypes. The activity of cefepime was reliable. All isolates of A hydrophila and A dhakensis carried an mcr-3-like colistin resistance gene and showed reduced susceptibility to colistin. Conclusions: Hepatobiliary tract was the most common infection site of Aeromonas spp., with A caviae being the dominant causative species. The resistance genotype and phenotype were often incongruent for ß-lactam agents.