Molecular Epidemiology of Carbapenem Resistant Klebsiella Pneumoniae in Northern China: Clinical Characteristics, Antimicrobial Resistance, Virulence and Geographic Distribution.

Purpose: In this article, we studied in detail 74 Carbapenem Resistant Klebsiella pneumoniae (CRKP) in Shanxi to provide essential insight into development of effective strategies for control of CRKP. Patients and Methods: From 2018 to 2021, we collected 74 clinical CRKP from 11 hospitals in Shanxi Province. Clinical data were obtained from medical records, and all isolates were subjected to antimicrobial susceptibility testing, multi locus sequence typing, capsular serotypes, resistant gene profiles and virulence gene profiles. The synergistic activity was performed by microdilution checkerboard method. Results: Our study found differences in the clinical characteristics of CRKP between regions in Shanxi. Sequence type (ST) 11 was the dominant ST in Shanxi; however, the ST types in Shanxi had become more diverse over time and the proportion of STs showed a more balanced distribution with a significant decrease in ST11. NDM was the most common carbapenemase in Shanxi. In addition, the STs, carbapenemases, serotypes and virulence gene distribution varied by region in Shanxi. Moreover, tigecycline in combination with carbapenems and aztreonam had an excellent synergistic effect on CRKP in vitro. Conclusion: The results of this study provide essential insight into development of effective strategies for control of CRKP in Shanxi.

Characteristics, Outcomes, and Clinical Indicators of Bloodstream Infections in Neutropenic Patients with Hematological Malignancies: A 7-Year Retrospective Study.

Purpose: The aim of this study was to investigate the current epidemiology, its changes during the study years, and inflammatory biomarkers of bacterial bloodstream infections (BSIs) in neutropenic patients with hematological malignancies. We assessed mortality risk factors and multidrug-resistant (MDR) gram-negative BSI predictors. Patients and Methods: We conducted a retrospective study from January 2015 to December 2021, which included adult neutropenic oncohematological patients with confirmed BSIs. We used univariable and multivariable analyses to analyze the risk factors. Each index's reliability for bacterial BSI diagnosis was assessed using the receiver-operating characteristic curve and area under the curve. Results: A total of 514 isolates were obtained from the 452 patients. The average mortality was 17.71%. Gram-negative organisms were the predominant causes of BSI. Escherichia coli was the most common microorganism (49.90%). The overall variation trend of the isolation rate of MDR and carbapenem-resistant gram-negative bacteria increased. Multivariate analysis indicated that: 1) neutropenia that lasted for more than 7 days, patients ≥ 60 years of age, septic shock, hospitalization for >20 days, BSI with a carbapenem-resistant strain, and treatment with linezolid or vancomycin in infections lasting less than 30 days were independent mortality risk factors; 2) severe neutropenia exceeding 7 days, unreasonable empirical therapy, and receipt of aminoglycosides or 3rd or 4th generation cephalosporins in infections lasting less than 30 days were independent risk factors of MDR gram-negative bacteria. Procalcitonin, absolute neutrophil count, and white blood cell indicate higher diagnostic accuracy for BSIs. Moreover, bacteria time to detection was better at differentiating Gram-negative and Gram-positive bacterial infections. Conclusion: We analyzed the risk factors for BSI neutropenic patients with hematological malignancies, the distribution of bacteria, antibiotic resistance, and the changes in clinical parameters. This single-center retrospective study may provide clinicians with novel insights into the diagnosis and treatment of BSI to improve future clinical outcomes.

Moderating effects of humanistic care and socioeconomic status on the relationship among pain intensity, psychological factors, and psychological function in adults with cancer pain from a province of China: A cross-sectional study.

Objective: The objective of this study is to explore whether humanistic care practiced by clinical pharmacists and socioeconomic status moderate the associations among pain intensity, psychological factors (catastrophizing and resilience), and psychological function (depression and anxiety) in cancer patients with low levels of education and income in the Shanxi province in the Northwest of China. Methods: Our sample comprised 123 adult inpatients with cancer pain. Demographic variables were obtained from the Hospital Information System of The Second Hospital of Shanxi Medical University. Pain intensity, psychological factors, and psychological functions were evaluated with four scales, and humanistic care was practiced with a part of the patients by clinical pharmacists. First, univariate analyses were conducted, followed by moderating effect models. Results: The incidence of depression and anxiety in patients with cancer pain in our sample were 48.78 and 41.46%, respectively. Low levels of psychological resilience (63.37, SD 21.74) were in this study. Pain intensity was significantly associated with humanistic care and anxiety. Humanistic care practiced by clinical pharmacists moderated not only the association between resilience and pain intensity but also the association between pain intensity and anxiety. Education levels moderated the relationship between pain intensity and the psychological factors of catastrophizing and resilience. Income levels moderated the association between resilience and anxiety. Conclusion: Humanistic care is essential in moderating the association among pain intensity, psychological factors, and psychological functions in Chinese cancer patients, especially those from lower-level counties and rural areas. Furthermore, socioeconomic statuses, such as education level and income, cannot easily change quickly. Still, proper humanistic care can relieve pain more effectively, reminding us that medical staff should implement effective personalized interventions to reduce patients' pain intensity.

Prevalence of antimicrobial use and healthcare-associated infections in China: Results from the first point prevalence survey in 18 hospitals in Shanxi Province.

OBJECTIVES: Inappropriate antimicrobial use (AMU) and healthcare-associated infections (HAIs) are important drivers of antimicrobial resistance, but data from the developing world are scarce. We conducted the first point prevalence survey (PPS) to determine the prevalence of AMU and HAIs and the suggested targeted interventions for appropriate AMU and HAI prevention in Shanxi Province, China. METHODS: A multicentre PPS was performed in 18 hospitals in Shanxi. Detailed data on AMU and HAI were collected using the Global-PPS method developed by the University of Antwerp and the methodology developed by the European Centre for Disease Prevention and Control, respectively. RESULTS: There were 2171 (28.2%) of the 7707 inpatients receiving at least one antimicrobial. The most commonly prescribed antimicrobials were levofloxacin (11.9%), ceftazidime (11.2%), and cefoperazone and beta-lactamase inhibitor (10.3%). Out of the total indications, 89.2% of antibiotics were prescribed for therapeutic, 8.0% for prophylaxis, and 2.8% for either unknown or other. Of the total surgical prophylaxis, 96.0% of antibiotics were given for more than one day. In general, antimicrobials were given mainly parenterally (95.4%) and empirically (83.3%). A total of 264 active HAIs were identified in 239 patients (3.1%), of which 139 (52.3%) were culture positive. The most common HAI was pneumonia (41.3%). CONCLUSIONS: This survey indicated the relatively low prevalence of AMU and HAIs in Shanxi Province. However, this study has also highlighted several priority areas and targets for quality improvement, and repeated PPSs in the future will be useful to gauge progress at controlling AMU and HAIs.

Antibiotic resistance and virulence characteristics of four carbapenem-resistant Klebsiella pneumoniae strains coharbouring blaKPC and blaNDM based on whole genome sequences from a tertiary general teaching hospital in central China between 2019 and 2021.

OBJECTIVE: Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection is a worldwide health issue that poses a serious threat to public health. This study summarizes the clinical features of four patients with CRKP coproducing NDM and KPC infections and further analyses the molecular typing, resistance and virulence factors of the four CRKP strains. METHODS: Of the twenty-two CRKP isolates, four strains coharbouring blaKPC and blaNDM isolated from four patients were screened by Sanger sequencing between October 2019 and April 2021. Demographics, clinical and pathological data of the four patients were collected through electronic medical records. Antimicrobial susceptibility testing, biofilm formation assays and serum bactericidal assays were performed on the four isolates. The antibiotic resistance and virulence genes were investigated by whole-genome sequencing. Sequence types (STs) were determined by multilocus sequence typing, and serotypes were identified by wzi gene sequencing. RESULTS: Three patients recovered, and one patient stopped treatment. Four strains were multiple carbapenemase producers: KPC-2, NDM-4, SME-5 and IMI-4 coproducer; KPC-2, NDM-1 and SME-3 coproducer; KPC-2, NDM-1 and IMI-3 coproducer; KPC-2 and NDM-5 coproducer. They also harboured ESBL genes and mutations in the efflux pump regulator genes. They were multidrug resistant but sensitive to tigecycline and colistin. Four isolates had moderate biofilm-forming abilities and carried various virulence genes, including siderophores, type 1 fimbriae and E. coli common pilus. Only the NO. 3 strain was resistant to the serum. The STs and serotypes of the four strains were ST11 and KL64, ST337 and none, ST307 and KL102KL149KL155, and ST29 and K54, respectively. CONCLUSION: Four CRKP strains coharbouring blaKPC and blaNDM also carried other carbapenemase genes. Notably, the NO. 1 isolate carrying four carbapenemase genes has not been reported globally until now. Four strains exhibited a high level of resistance to multiple antibiotics. Additionally, three of the four patients were exposed to invasive medical devices that provided an environment for biofilm formation. Meanwhile, three strains with adhesion genes as moderate biofilm formers might form biofilms resulting in long hospital stays, increasing therapeutic difficulty, and even treatment failure. This study reminds clinicians that CRKP strains with multiple carbapenemase genes emerged in our hospital, and stronger measures should be taken to the control of nosocomial infections.

Evaluation of the effect of pharmaceutical care during inpatient treatment in a department of neurology: A retrospective study.

Common drug-related problems during neurology inpatient treatment can affect expected health results. Some interventions need to be implemented to reduce DRPs. To explore the effect of care from clinical pharmacists during inpatient treatment. Inpatients treated in the department of neurology in the Second Hospital of Shanxi Medical University between January 1 to December 31, 2019, were retrospectively included. Those who received care from the clinical pharmacist service were assigned to the pharma-care group while the other patients were assigned to the control group. From the perspective of drugs, the two groups were compared in terms of types, antimicrobial use, and key monitoring of drug use. From the perspective of patients, the two groups were compared in terms of length of stay, hospital cost, drug cost and proportion. Propensity score matching was used to balance the baseline characteristics. A total of 2684 patients were included 554 in the pharma-care group and 2130 in the control group with a median of 9 days (range, 3-30 days) hospital stay. The groups showed no significant difference in age or gender. Length of stay, the proportion of drug cost, number of adverse events, cost of antibacterial agents, use of a single antibacterial agent, and use of three or more different antibacterial agents were similar between the groups. Medicine expenses cost more in the pharma-care group. The cost and types of intensive monitoring drugs were similar, but Defined Daily Doses were lower in the control group. While clinical pharmacists may play a positive role in the pharmaceutical care of inpatients, in this study the benefits were not obvious. This may be because of the small number of clinical pharmacists in the department of neurology with narrow coverage.

Bacteriological Profile and Antimicrobial Susceptibility Patterns of Gram-Negative Bloodstream Infection and Risk Factors Associated with Mortality and Drug Resistance: A Retrospective Study from Shanxi, China.

Objective: The aim of this study was to analyze the epidemiological of gram-negative bloodstream infection (GNBSI) and establish a risk prediction model for mortality and acquiring multidrug resistant (MDR), the extended spectrum beta-lactamases (ESBLs) producing and carbapenem-resistant (CR) GNBSI. Methods: This retrospective study covered five years from January 2015 to December 2019. Data were obtained from Hospital Information System (HIS) and microbiology department records. The risk factors for mortality and acquiring MDR, ESBLs-producing and CR GNBSI were analyzed by univariable and multivariable analysis. Results: A total of 1018 GNBSI cases were collected. A majority of GNBSI patients were in hematology ward (23.77%). There were 38.61% patients who were assigned in the 41-60 age group. Escherichia coli was the most common gram-negative organism (49.90%). Among isolates of GNBSI, 40.47% were found to be MDR strains, 34.09% were found to be ESBLs-producing strains and 7.06% were found to be CR strains. Escherichia coli was the most common MDR (71.36%) and ESBLs-producing strain (77.81%). Acinetobacter baumannii was the most common CR isolate (46.15%). Multivariate analysis indicated that diabetes mellitus, solid organ tumor, non-fermentative bacteria, MDR strain, central venous cannula, urinary catheter, therapy with carbapenems or tigecycline prior 30 days of infection were independent mortality risk factors for GNBSIs. Over all, therapy with tigecycline prior 30 days of infection was the mutual predictor for mortality of GNBSI, acquiring MDR, ESBLs-producing and CR GNBSI (OR, 8.221, OR, 3.963, OR, 3.588, OR, 9.222, respectively, all p < 0.001). Conclusion: Collectively, our study implies that patients who were diagnosed as GNBSI had a younger age. Therapy with tigecycline was the mutual and paramount predictor for mortality of GNBSI, acquiring MDR, ESBLs-producing and CR GNBSI. Our investigation had provided a theoretical basis for the use of antibiotics and prevention and control of hospital infection in our region.

Mortality Risk Factors and Prognostic Analysis of Patients with Multi-Drug Resistant Enterobacterales Infection.

Background: The data from the China Network Antibacterial Surveillance Center (http://www.chinets.com) showed that the prevalence of Escherichia coli (E. coli), Klebsiella pneumoniae (KP), and Enterobacter cloacae (ecl), was 18.96%, 14.12%, and 2.74% in 2022, respectively. The resistance rates of E. coli and KP to 3rd or 4th generation cephalosporins were 51.7% and 22.1%, to carbapenems was 1.7% and 3.9%, to quinolones was 55.9% in Shanxi. The generation of extended-spectrum beta-lactamases (ESBLs) is a major mechanism resulting in drug resistance in Enterobacterales. To determine the mortality risk factors of multi-drug resistant Enterobacterales (MDRE) and multi-drug resistant Klebsiella pneumoniae (MDR-KP) infection. Methods: 91 MDR strains from 91 patients were collected from 2015 to 2019 in the second hospital of Shanxi Medical University. The mortality risk factors for the MDRE infections and clinical outcomes were analyzed by univariable and multivariable analysis. The independent predictors of 30-day mortality were analyzed through the Cox regression analysis including the variables with a value <0.2. Results: The majority of patients were admitted to ICUs. Pulmonary infection was a major infection (43.96%, 40/91). Thirty-three (36.26%, 33/91) strains of MDR-KP were only detected in 2018. The proportion of multi-drug resistant Escherichia coli (MDR E. coli) and multi-drug resistant Enterobacter cloacae (MDR ecl) were 16.48% (15/91) and 17.58% (16/91), respectively. The presence of cerebrovascular diseases (OR, 4.046; 95%Cl, 1.434-11.418; P=0.008) and central venous catheterization (OR, 4.543; 95%Cl, 1.338-15.425; P=0.015) were associated with mortality in patients with MDRE infections. Endotracheal intubation (OR, 4.654; 95%Cl, 1.5-14.438; P=0.008) was an independent mortality risk factor for patients infected with MDR-KP strains. Patients who received aminoglycoside antibiotics (P=0.057) had a higher 30-day survival rate. The ß-lactam antibiotics were the major agent in the clinic. Conclusion: This study implies that patients with cerebrovascular diseases, central venous catheterization, and endotracheal intubation are at risk of carrying MDR isolates.

Three Novel Sequence Types Carbapenem-Resistant Klebsiella pneumoniae Strains ST5365, ST5587, ST5647 Isolated from Two Tertiary Teaching General Hospitals in Shanxi Province, in North China: Molecular Characteristics, Resistance and Virulence Factors.

Background: Carbapenem-resistant Klebsiella pneumoniae (CRKP) represents a significant threat to public health and has already drawn worldwide attention. Hence, we aim to comprehensively analyze the case condition, as well as molecular epidemiology, resistance and virulence of three CRKP isolates with new sequence types (STs). Methods: Three CRKP were collected from November 2019 to April 2021. The three patients' clinical characteristics were analyzed through His system. In order to screen phenotype of metallo-carbapenemase, the modified Carbapenem Inactivation Method (mCIM) and EDTA-modified Carbapenem Inactivation Method (eCIM) were conducted. Three isolates were subjected to antimicrobial susceptibility testing (AST) using the agar dilution method or minimal broth dilution method. The string test, the sedimentation assay, biofilm formation and the serum resistance assay were performed as phenotypic experiments to assist in evaluating virulence. The presence of resistance and virulence genes were detected by Whole-Genome Sequencing (WGS). Serotypes and new STs were compared and determined by multi-locus sequence typing (MLST). Results: Overall, all Klebsiella pneumoniae isolates were multi-resistant, but sensitive to tigecycline and colistin. Among them, all formed biofilms, strain 1 and strain 2 were classified as moderate-producers, while strain 3 as weak-producer. The results of the serum resistance assay indicated that only strain 2 was resistant. From WGS analysis, it showed that all isolates co-harbored multiple resistance genes, such as carbapenemase genes, sulfonamides, fluoroquinolones, aminoglycosides, and tetracyclines. Meanwhile, several virulence genes were also contained, including siderophores, fimbriae, capsule and lipopolysaccharides-associated genes. The serotypes of strain 1 and strain 2 manifested K35 and KL47, respectively. Conclusion: Three novel ST5365, ST5587, ST5647 were first discovered in North China. Our study suggested that we should pay more attention to their resistance. And the results will help treat CRKP infections caused by these novel STs.

Epidemiology of patients with central nervous system infections, mainly neurosurgical patients: a retrospective study from 2012 to 2019 in a teaching hospital in China.

BACKGROUND: Central nervous system (CNS) infections are relatively rare but are associated with high mortality worldwide. Empirical antimicrobial therapy is crucial for the survival of patients with CNS infections, and should be based on the knowledge of the pathogen distribution and antibiotic sensitivities. The aim of this study was to investigate the features of pathogens in patients with CNS infections in North China and evaluate the risk factors for mortality and multi-drug-resistant (MDR) bacterial infections. METHODS: A retrospective study was conducted with patients with positive cerebrospinal fluid (CSF) cultures in a teaching hospital from January 2012 to December 2019. The following data were collected: demographic characteristics, laboratory data, causative organisms and antimicrobial sensitivity results. Data were analyzed with SPSS 16.0. Univariate analysis and binary logistic regression analyses were performed to identify the risk factors for mortality and MDR bacterial infections. RESULTS: A total of 72 patients were diagnosed with CNS infections, and 86 isolates were identified. The proportions of Gram-positive bacteria, Gram-negative bacteria and fungi were 59.3, 30.2 and 10.5%, respectively. The predominant Gram-positive bacteria was Coagulase-negative Staphylococci. Acinetobacter baumannii, Escherichia coli and Klebsiella spp. were the predominant Gram-negative bacteria. Compared to 2012-2015 years, the proportion of Gram-negative bacteria increased markedly during 2016-2019 years. Coagulase-negative Staphylococci, Streptococcus pneumoniae and Enterococcus faecium had 100% sensitivity to vancomycin, teicoplanin and linezolid. Acinetobacter baumannii and Klebsiella pneumoniae were 100% sensitive to tigecycline. Escherichia coli had 100% sensitivity to amikacin, meropenem and imipenem. The overall mortality rate in the 72 patients was 30.6%. In multivariate analysis, age > 50 years, pulmonary infections and CSF glucose level < the normal value were associated with poor outcomes. CSF adenosine deaminase level > the normal value and the presence of external ventricular drainage/lumbar cistern drainage were associated with MDR bacterial infections. CONCLUSIONS: The mortality rate due to CNS infections reached 30.6% in our study. The proportion of Gram-negative bacteria has increased markedly in recent years. We should give particular attention to patients with risk factors for mortality and MDR bacterial infections mentioned above.

Co-Production of NDM-1, CTX-M-9 Family and mcr-1 in a Klebsiella pneumoniae ST4564 Strain in China.

PURPOSE: To identify novel sequence types 4564 (ST4564) carbapenem-resistant Klebsiella pneumoniae (CRKP). Characterizing the feature of the clinic, resistance, and virulence of a co-producing NDM-1 and CTX-M-9 family and mcr-1 ST4564 strain. METHODS: A novel ST4564 CRKP was collected from June 2018 to July 2018. We investigated its antimicrobial susceptibility by the microdilution method. Using the modified carbapenem inactivation method (mCIM) to screen phenotype of carbapenemases. Resistance mechanisms, virulence-associated genes, multilocus sequence typing (MLST), and capsular serotypes were characterized by polymerase chain reaction (PCR) and DNA sequencing. Next-generation sequencing (NGS) was carried out to determine the genetic features of carbapenem resistance and virulence. RESULTS: ST4564, co-carrying NDM-1, CTX-M-9 and mcr-1, was resistant to carbapenems, cephamycin, third- or fourth-generation cephalosporins, ß-lactam combination agents, quinolones and tigecycline but remained susceptible to amikacin (AMK) and colistin (COL). Through the NGS analysis with the G+C content of 56.65%, multiple resistance and virulence genomes were detected. The genes encoding the ß-lactams, aminoglycosides, quinolones, macrolides, sulfonamide, polysaccharide capsule, type-I fimbriae cluster, siderophore genes, transporter and pumps, T6SS and pullulanase secretion protein. goeBURST analysis showed that ST4564 belonged to the CC1571 and it was not related to the prevalent high-risk clones. CONCLUSION: We first identified the novel ST4564 CRKP. Our finding suggested that the urgent need for infection control of the new clone to prevent it from becoming a high-risk clone of CRKP.

Polymorphism of MTHFR C677T Gene and the Associations with the Severity of Essential Hypertension in Northern Chinese Population.

OBJECTIVE: Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme of homocysteine metabolism and is closely related to the occurrence of hypertension. The aim of this study was to investigate the polymorphism of the (MTHFR) C677T and the factors influencing the severity of hypertension. Material and Methods. A total of 985 subjects were enrolled to analyze the polymorphisms of the MTHFR C677T gene by polymerase chain reaction (PCR). 306 people with essential hypertension were selected from 985 subjects to estimate the severity of hypertension by the ordinal multivariate logistical regression model. RESULTS: The frequencies of CC, CT, and TT genotypes were 19.5%, 49.95%, and 30.46%, respectively. The allelic frequency of mutant T was 55.43%. The plasma homocysteine level of the homozygous TT in individuals was significantly higher than in those with CC or CT (P < 0.01). MTHFR677CT genotype, MTHFR677TT genotype, smoking, family history of hypertension, Hcy, and triglycerides (TG) were independent risk factors for the severity of hypertension (OR = 2.29, 2.24, 2.04, 1.81, 1.04, 1.26). CONCLUSION: MTHFR gene, smoking, family history of hypertension, Hcy, and triglycerides could be important genetic and high-risk factors of the development of severe hypertension in northern Chinese. These factors will contribute to the identification of high-risk populations of hypertension and facilitate the development of hypertension control strategies.

Emergence of NDM-5-Producing Carbapenem-Resistant Klebsiella pneumoniae and SIM-Producing Hypervirulent Klebsiella pneumoniae Isolated from Aseptic Body Fluid in a Large Tertiary Hospital, 2017-2018: Genetic Traits of blaNDM-Like and blaSIM-Like Genes as Determined by NGS.

PURPOSE: To characterize the clinical, resistance, and virulence features of carbapenem-resistant Klebsiella pneumonaie (CRKP) and hypervirulent Klebsiella pneumoniae (hvKP) and also provide an effective selection of drug in CRKP and hvKP treatment. MATERIALS AND METHODS: Twelve strains were collected and investigated these isolates for their antimicrobial susceptibility and molecular features. Resistance mechanisms, virulence-associated genes, multilocus sequence typing (MLST), and serotypes were detected by PCR and sequencing. Next general sequencing (NGS) was carried out to determine the features of carbapenem resistance and virulence. The synergistic activity of tigecycline-imipenem (TGC+IPM), tigecycline-meropenem (TGC+MEM), and tigecycline-aztreonam (TGC+ATM) combinations were performed by microdilution checkerboard method. RESULTS: Eleven CRKP and one hvKP strains were collected. All strains showed highly sensitive rates to tigecycline (TGC) and amikacin (AMK). NDM (33.3%, 4/12) was the main resistance mechanism and MLST assigned 3 of them to ST11. CTX-M-producing (n = 1) and KPC-2-producing (n = 1) isolates belonged to ST147 and ST11, respectively. The MICs of ATM and quinolones in NDM-1 CRKP and NDM-5 CRKP strains were different. The serotype of the majority strains was KL22KL137 (58.3%, 7/12), hvKP stain belonged to K64. CRKP strains harbored plasmid-mediated quinolone resistance genes (oqxA, oqxB, qnrS, qnrB), ß-lactams (bla CTX-M-3), aminoglycosides, type I and type III fimbriae genes, siderophore genes, and transporter and pumps. SIM-producing ST1764 K64 showed typical features of hvKP, showing hypermucoviscosity phenotype. The virulence genes, including rmpA2, alls and aerobactin genes, linked to hvKP, were found in ST1764 hvKP. hvKP was sensitive to quinolone; also, oqxA gene was detected. All TGC combinations showed highly synergistic effects and TGC+IPM was more effective treatment. CONCLUSION: We first identified the NDM-5-producing ST690 CRKP and SIM-producing ST1764 hvKP strains in Shanxi province. Tigecycline-carbapenem combinations were available treatments for CRKP.

Successful control of the first carbapenem-resistant Klebsiella pneumoniae outbreak in a Chinese hospital 2017-2019.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is considered as a serious global threat. CRKPs occurred only sporadically in the Second Hospital of Shanxi Medical University. Our study aimed to investigate and control the first outbreak of CRKP in our hospital occurred between October 2017 and August 2019. METHODS: The antimicrobial stewardship (AMS) workers have been implemented control measures properly. Clinical and epidemiological data were retrospectively collected from medical records. Carbapenemase genes were detected by modified carbapenem inactivation method (mCIM) test and the EDTA-modified carbapenem inactivation method (eCIM) test. Resistance genes were identified by polymerase chain reaction (PCR) and sequencing. Genetic relatedness was studied by multilocus sequence typing (MLST). RESULTS: During the outbreak, 31 patients were infected with CRKP isolates. 20 (64.5%) patients were infected with KPC-2 and/or NDM-1 producing K. pneumoniae. Mostly MLST-sequence types belonged to ST11 (21/31). The outbreak was two major K. pneumoniae clusters present in epidemiologically linked patients. CONCLUSIONS: Setting up AMS workers is potentially a highly efficient strategy for the successful control of the outbreak. A multimodal and multidisciplinary infection control strategy proved to be crucial. The emergence of CRKP in our hospital emphasizes the importance of continuous monitoring of these isolates, which helps to limit the spread of CRKPs and improve the level of management.

The effect of inpatient pharmaceutical care on nephrotic syndrome patients after discharge: a randomized controlled trial.

Background Clinical pharmacists can play an important role in chronic diseases management, but limited attention has been given to the pharmaceutical care of nephrotic syndrome patients. Objective To evaluate the impact of inpatient pharmaceutical care on medication adherence and clinical outcomes in nephrotic syndrome patients. Setting A tertiary first-class hospital in Shanxi, China. Method We conducted a randomized controlled trial on 61 patients with nephrotic syndrome. The intervention consisted of medication reconciliation, pharmacist visits every day, discharge counseling and education by 2 certificated pharmacist, while the control group received usual care. Assessments were performed at baseline, month-1, month-3 and month-6 after hospital discharge. Main outcome measure medication adherence and patients' clinical outcomes. Results 61 patient completed the trial. Baseline variables were comparable between the two groups. The decline in medication adherence of patients in the intervention group after hospital discharge was restrained effectively at month-6 (p < 0.05). However, the groups did not differ in clinical outcomes, medication discrepancies, adverse drug events and readmission rate. The rate of return visits of the pharmaceutical care group was higher at month-1 and month-6 after discharge (p < 0.05). Conclusion Pharmaceutical inpatient care improved adherence in patients with nephrotic syndrome after hospital discharge, the effect of the intervention on clinical outcomes, medication discrepancies, adverse drug events or readmission was insignificant. These results are promising but should be tested in other settings prior to broader dissemination.

The role of clinical pharmacist trainees in medication reconciliation process at hospital admission.

Background Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the prevalence and potential risk factors involved in medication discrepancies in China. Objective To determine the frequency of medication discrepancies and the associated risk factors and evaluate the potential harmsof errors prevented by pharmacist trainees performing medication reconciliation process. Setting A tertiary hospital in Shanxi, China. Method Medication reconciliation was conducted at admission to four clinical departments including cardiology, nephrology, endocrinology and pneumology department between 2019 Feb 1st and 2019 Aug 31st by clinical pharmacist trainees. All unintentional medication discrepancies were presented to the expert panel to evaluate. Associations between unintentional medication discrepancies and various factors were examined. Main outcome measure The primary outcome was the prevalence of unintentional medication discrepancies as well as the associated risk factors. Results Overall, 331 patients were included (mean age 59.7 ± 15.2 years; 176 men). The reconciliation process identified 511 drug discrepancies, 98 of which were unintentional medication discrepancies; these occurred in 74 patients. The most common unintentional medication discrepancies type was omission (40.8%), followed by incorrect dose (25.5%), and 73.5% could have caused patients moderate to significant harm and complications. 5 or more drugs and 2 or more chronic diseases at admission associated with unintentional medication discrepancies in a logistic regression analysis. Conclusion Medication reconciliation performed by pharmacist trainees upon admission can reduce unintentional medication discrepancies. Patients taking 5 or more drugs and experiencing more than two chronic diseases were found to be particularly at risk.

Association of CYP2C19 and UGT1A4 polymorphisms with voriconazole-induced liver injury.

Aim: This study investigated the association between voriconazole-induced liver injury and gene polymorphisms of CYP2C19 and UGT1A4. Materials & methods: Thirty-eight adult patients who received voriconazole therapy were included in the study. Genotype of CYP2C19 was detected using gene chip hybrid analysis. The UGT1A4 142T>G was genotyped using PCR-RFLP analysis. Results: Ten patients (26.3%) had voriconazole-induced liver injury and were considered as the case group There was no significant difference between the two groups in genotype and allele frequencies of CYP2C19*2 and UGT1A4 142T>G (p > 0.05), however, the GA frequency of CYP2C19 *3 in the drug-induced liver injury case group was higher than that in the control group (p < 0.05). Compared with patients carrying *1/*1 or *1/*2, there was no significant difference in voriconazole trough concentration of the patients with *1/*3 (p > 0.05). Conclusion: There was no significant correlation between voriconazole-induced liver injury and gene polymorphisms of CYP2C19 and UGT1A4.

Regulation of cadmium tolerance and accumulation by miR156 in Arabidopsis.

Plants have evolved effective strategies to cope with heavy metals Cd toxicity, but the regulatory mechanism underlying Cd tolerance and accumulation are still poorly understood. miR156 has been shown to be the master regulator of development and stress response in plants. However, whether miR156 is also involved in plant Cd stress response remains unknown. Here, we show that plants overexpressing miR156 (miR156OE) accumulated significantly less Cd in the shoot, and conferred enhanced tolerance to Cd stress. Plants with a knocked-down level of miR156 (MIM156) were sensitive to Cd stress, and accumulated significantly higher Cd. Under Cd stress, miR156OE had significantly longer primary root length, higher biomass and chlorophyll content, increased activities of antioxidative enzymes and lower levels of endogenous reactive oxygen species (ROS), while MIM156 had the opposite phenotype. To investigate the underlying mechanism of miR156-mediated Cd stress response in Arabidopsis, we profiled the expression of several Cd transporter genes. The expression of Cd uptake transporter of AtZIP1、AtZIP2 and vacuole segregated transporter AtABCC1 was significantly elevated in miR156OE, whereas it was significantly reduced in MIM156. MIM156 also led to an elevated level of AtHMA4 responsible for transporting Cd from the root to the shoot. Our results indicate that miR156 acts as a positive regulator of plant tolerance to Cd stress by modulating ROS levels and Cd uptake/transport genes expression. Therefore, our study adds a new layer of regulatory mechanism for Cd transport and tolerance in plants, and provides a perspective to regulate Cd transport artificially by modulating plant vegetative growth and development using miR156.

The effect of the sub-minimal inhibitory concentration and the concentrations within resistant mutation window of ciprofloxacin on MIC, swimming motility and biofilm formation of Pseudomonas aeruginosa.

OBJECTIVE: To explore the effect of sub-minimal inhibitory concentration (sub-MIC) and concentrations within resistant mutation window (MSW) of ciprofloxacin (CIP) on minimal inhibitory concentration (MIC), swimming motility and biofilm formation of Pseudomonas aeruginosa, and also to investigate the correlation between swimming motility and genes expression of lasI, lasR, rhlI, rhlR and pqsR. METHODS: The collected strains were incubated under four different concentrations for 5 days. The MIC and mutant prevention concentration (MPC) were measured by the agar dilution method. The diameter of turbid cycle was used to signify the swimming motility. The biofilm formation was measured by the crystal violet stain method. The genes expression of lasI, lasR, rhlI, rhlR and pqsR were measured by RT-PCR. RESULTS: A total of 11 P. aeruginosa which sensitive to CIP were collected. The incubation within concentrations of MSW made MICs to CIP increased more obviously than under sub-MIC (P < 0.05). The swimming motility showed a trend of being inhibited first and then promoted over time under sub-MIC (P < 0.05), whereas, it was promoted under concentrations within MSW. The biofilm formation was significantly promoted under the concentration of 4×MIC (P < 0.05). Under sub-MIC, the genes expression of rhlR and pqsR had a middle level positive correlation with the promotion of the swimming motility (P < 0.05, r = 0.788 and P < 0.05, r = 0.652, respectively). CONCLUSIONS: Under the concentration of sub-MIC (0.5×MIC) and the concentrations within MSW (1×MIC, 2×MIC and 4×MIC), the effect of CIP on MICs, swimming motility and biofilm formation of P.aeruginosa was quite different. The genes expression of rhlR and pqsR had a middle level positive correlation with the promotion of the swimming motility.

Mutations in gyrB play an important role in ciprofloxacin-resistant Pseudomonas aeruginosa.

PURPOSE: To investigate the main molecular resistance mechanisms to fluoroquinolones (FQs) in Pseudomonas aeruginosa and also to investigate the effect of time and concentration on mutations in resistance genes. MATERIALS AND METHODS: The clinical isolates of P. aeruginosa which are sensitive to ciprofloxacin (CIP) or levofloxacin (LEV) were collected. The isolates were incubated with different concentrations of CIP or LEV for 5 days and the minimal inhibitory concentrations (MICs) of CIP, LEV and ofloxacin (OFX) were measured. The MIC of FQs to P. aeruginosa was measured by the agar dilution method. FQ resistance determining regions of gyrA, gyrB, parC and parE were amplified by PCR, and mutations in four genes were explored using sequence analysis with the Snapgene software. The relative expression levels of two efflux pumps genes (mexA and mexE) were measured by quantitative reverse transcription PCR. RESULTS: A total of eleven isolates were collected from the Second Hospital of Shanxi Medical University. Amino acid alterations in gyrA and gyrB were mainly detected in resistant mutants, and the percentage of strains with amino acid alterations in gyrB was significantly higher than that in gyrA (P<0.001). MICs of strains with mutations both in gyrA and gyrB were not significantly higher than those of strains with mutations only in gyrB (P>0.05). No amino acid alterations were detected in genes of parC and parE. In both gyrA and gyrB, the number of amino acid alterations increased with incubation time prolonged and increased with increasing incubation concentration. CONCLUSION: CIP was more competent than LEV in making P. aeruginosa resistant to in vitro selection. Mutations occurring in gyrB played an important role in FQ resistance of P. aeruginosa in vitro selection.