DiscussionThe occurrence and spread of infections resulting from ESBL-producing organisms have been well documented in countries of Europe, Asia and North America.11 In contrast, data on the epidemiology of ESBL enzymes is very limited in Nigeria. Molecular analysis of eight Nigerian ESBL-producing Enterobacter species in 2001 detected only TEM and SHV-like ESBLs and no CTX-M types.12 In a study of Klebsiella pneumoniae isolates associated with community-acquired urinary tract infections between 2002 and 2003 in Ibadan, Nigeria, CTX-M group 1, -like enzymes were found in 17 (57%), but CTX-M-15 was identified in only two isolates.13 Olowe et al. investigated the occurrence of CTX-M ESBL-producing E. coli and found nine of 79 ampicillin-resistant hospital isolates to be ESBL producers.14 More recently, a case of necrotising fasciitis was reported in a Nigerian patient in the UK.15 Morganella morganii and Citrobacter freundii carrying the CTX-M-15 ESBL gene were isolated from the patient, highlighting the presence of CTX-M genes in Africa even though there is a scarcity of reports in the literature. Here, we describe a case of prolonged, uncontrolled fever found to be due to ESBL-producing K. pneumoniae. To the best of our knowledge, this is the first documented clinical course and outcome of ESBL-producing bacterial infection in Nigeria. Failure to recognise and initially diagnose the presence of an ESBL-producing organism resulted in considerable expense in the management of the infection. This includes the cost of different courses of ineffective antibiotics for five weeks, exchange blood transfusions and whole blood transfusions, as well as hospital charges resulting from prolonged stay in hospital. The estimated avoidable cost of supportive therapy and investigation related to possible alternative diagnoses was almost $600 in a country where the average annual per capita income is $2300 and health care resources are severely limited. The clinical diagnostic microbiology laboratory plays a crucial part in the detection and reporting of ESBL-producing bacteria, and it is important that laboratories be fully aware of the significance of ESBL-producing organisms and the best methods for detecting them, as in our case. Resource-limited hospitals can incur prohibitive costs associated with ESBL-producer infections because of prolonged supportive therapy and treatment failure following the use of readily available antibiotics. Diagnostic improvements to allow routine detection and reporting of ESBL production in Enterobacteriaceae will help greatly in avoiding these costs. Acknowledgements This work was supported by a Branco Weiss Fellowship (awarded to INO) from the Society-in-Science, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland. Competing interests The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. Authors’ contributions O.A.A. (Obafemi Awolowo University) coordinated the research. O.A. (Obafemi Awolowo University Teaching Hospitals Complex) A.A.O. (Obafemi Awolowo University Teaching Hospitals Complex), O.A.A. and O.O.A. (Obafemi Awolowo University Teaching Hospitals Complex) managed the patient (case) clinically. A.A.O., O.A.A. and B.W.O. (Obafemi Awolowo University) performed microbiological testing whilst I.N.O. carried out molecular experiments. A.O.A. and I.N.O. (Haverford College) drafted the paper, to which O.A., B.W.O., O.O.A. and A.A.O. contributed. O.A.A. and I.N.O. undertook revision of the manuscript. All authors approved the final version. 1.10.1007/BF0164135563213572.10.1086/499819164471113.10.1016/j.mib.2006.08.011169428994.10.1128/AAC.46.12.4038-4040.2002124357215.10.1586/14787210.6.5.657188474046.Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing: twentieth informational supplement. CLSI document M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010. 7.10.1128/AAC.39.1.18576953048.10.1128/AAC.45.9.2658-2661.2001115025489.10.1128/AAC.01540-071845812810.10.1093/jac/dkg25611.10.1016/S1473-3099(08)70041-01829133812.10.1128/JCM.41.5.2197-2200.20031273427813.10.1093/jac/dki4291631918114.10.1016/j.ijantimicag.2009.10.0042002222115. 10.1099/jmm.0.021998-020813849