Complicated urinary tract infection caused by extended spectrum β-lactamase-producing Escherichia coli

With great interest, we read the article by Pacheco et al in the Journal of Microbiology, Immunology and Infection, which reported that multidrug-resistant, extended-spectrum b-lactamase (ESBL)-producing Escherichia coli is an important pathogen in nosocomial urinary tract infection, causing great concern in therapeutic failure. Here, we report a patient who was diagnosed with complicated urinary tract infection caused by ESBL-producing E. coli and complicating obstructive uropathy by malakoplakia. We performed multiple-site biopsies of the bladder and ureter to verify the diagnosis and observed MichaeliseGutmann bodies microscopically, which is the characteristic of malakoplakia. It is a challenge for the clinician for managing such a case infected with emerging resistant strains complicating with malakoplakia. This 83-year-old male patient had a history of rectal adenocarcinoma, stage T3N0M0, status postoperation, and chemotherapy. He was suffering from fever, left flank pain, and dysuria on admission. The results of the laboratory data were as follows: hemoglobin, 10.6 mg/dL; white blood cells count, 14,800 cells/mL; and platelet count, 178,000 cells/ mL. The urine routine examinations showed pyuria and bacteriuria. He empirically received antibiotic therapy with 1-g cefazolin intravenous (iv) drip every 8 hours. The image study of abdominal sonogram revealed left-sided hydronephrosis. The percutaneous nephrostomy plus antegrade pyelography showed hydronephrosis and dilatation of the lower third ureter (Fig. 1A). Endoscopic findings of the bladder and ureter showed some soft yellowish tumor-like plaques over the bladder and ureter mucosa. The pathological findings of biopsy and resection specimens revealed