Background: Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection that results in the presence of gas in the renal parenchyma, collecting system, and surrounding tissues. Up to 95% of patients with EPN have underlying uncontrolled diabetes mellitus. Emphysematous cholecystitis (EC) is a necrotizing infection defined by the presence of gas in the gallbladder. Concurrent presentation of EPN and EC is limited to anecdotal cases in the literature. Case Report: We present the case of a 44-year-old female who arrived at the emergency department with signs of septic shock and diffuse abdominal pain. Diagnosis of EPN and EC was confirmed. Because the patient did not improve after aggressive medical therapy and percutaneous drainage and cholecystostomy, she was taken to surgery for emergency nephrectomy and cholecystectomy. Conclusion:In unusually extensive and severe cases of EPN, medical and minimally invasive procedures are not enough to control the infection. More aggressive management, including emergency surgery, should be implemented in selected patients who present with refractory septic shock associated with extensive disease.

Objective: To describe the causal agents, prevalence of antimicrobial resistance, and risk factors associated with extended spectrum beta-lactamase (ESBL)-producing agents in urinary tract infections (UTIs). Materials and methods: A retrospective study was conducted at a tertiary care hospital in Monterrey, Mexico. Inclusion criteria were patients that clinically presented with a UTI and had a positive urine culture, within the time frame of March to October 2017. The association with ESBL-producing agents was determined through the Χ2 test for categorical variables. Statistical significance was set at a p <0.05, utilizing SPSS version 20.0 software. Results: A total of 353 positive urine cultures were confirmed. ESBL production was found in 21.5% of the strains. There was a high level of resistance (>50%) to amoxicillin-clavulanate, ciprofloxacin, levofloxacin, fosfomycin, and trimethoprim-sulfamethoxazole and moderate resistance (10-50%) to gentamicin and ceftriaxone. Amikacin, ertapenem, nitrofurantoin, and colistin had the lowest resistance rates (<10%). The ESBL-producing agents were associated with complicated UTI (p≤0.0001). The comorbidities associated with ESBL-positive UTIs were diabetes mellitus (p=0.02) and immunodeficiency (p=0.008), as was having undergone radiotherapy (p=0.025) and previous antibiotic use (p≤0.001). Limitations: The clonal relationship of isolates, especially of E. coli, was not analyzed. We could not establish whether there was a high level of genetic diversity between the isolates or whether independent acquisition or cross-transmission occurred. Value: We evaluated the epidemiologic characteristics of the ESBL-producing agents in UTIs at a Mexican tertiary care hospital. Conclusions: One out of every five UTIs was caused by ESBLs in our study population. There was a high level of resistance to the antibiotics used as first-line empiric therapy in the patients studied.

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