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The emergence of third-generation cephalosporin resistance in  Escherichia coli  is increasing at an alarming rate in many countries. Thus, the aim of this study was to analyze co-infecting  bla  CTX-M -producing pathogenic  E. coli  isolates linked to three school outbreaks. Among 66  E. coli  isolates, 44 were identified as ETEC O25, an ETEC isolate serotype was O2, and the other 21 were confirmed as EAEC O44. Interestingly, six patients were co-infected with EAEC O44 and ETEC O25. For these isolates, molecular analysis [antibiotic susceptibility testing, identification of the β-lactamase gene, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE)] was performed for further characterization. In addition, the transmission capacity of  bla  CTX-M  genes was examined by conjugation experiments. Whole-genome sequencing (WGS) was performed on representative EAEC O44 and ETEC O25 isolates associated with co-infection and single-infection. All isolates were resistant to cefotaxime and ceftriaxone. All EAEC isolates carried the  bla  CTX-M-14  gene and all ETEC isolates the  bla  CTX-M-15  gene, as detected by multiplex PCR and sequencing analysis. Sequence type and PFGE results indicated three different patterns depending on the O serotype. WGS results of representative isolates revealed that the ETEC O25 strains harbored  bla  CTX-M-15  located on IncK plasmids associated with the Δ bla  TEM - bla  CTX-M-15 - orf477  transposon. The representative EAEC O44 isolates carried  bla  CTX-M-14  on the chromosome, which was surrounded by the IS Ecp1 - bla  CTX-M-14 - IS903  transposon. To the best of our knowledge, this is the first report of co-infection with chromosomally located  bla  CTX-M-14  and plasmid-encoding  bla  CTX-M-15  in pathogenic  E. coli . Our findings indicate that resistance genes in clinical isolates can spread through concurrent combinations of chromosomes and plasmids.

Co-infection With Chromosomally-Located blaCTX-M-14 and Plasmid-Encoding blaCTX-M-15 in Pathogenic Escherichia coli in the Republic of Korea