Startseite Epidemiological study of carbapenem-resistant Klebsiella pneumoniae
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Epidemiological study of carbapenem-resistant Klebsiella pneumoniae

  • Di Lin , Jian Chen , Yan Yang , Jun Cheng EMAIL logo und Changgui Sun EMAIL logo
Veröffentlicht/Copyright: 16. Oktober 2018
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Open Medicine
Aus der Zeitschrift Open Medicine Band 13 Heft 1

Abstract

Background

This research is aimed to study the resistance and molecular epidemiological characteristics of carbapenem-resistant Klebsiella pneumoniae (CRKP).

Methodology

38 isolated CRKP strains were collected from clinical specimens.

Results

The resistance rates were more than 70.0%. Ampicillin had the highest rates among them (100.0%). 34 strains (89.5%) among the 38 CRKP strains carried blaKPC-2 gene, and 3 strains (7.9%) carried blaIMP-4 gene. 36 strains (94.7%) among the 38 CRKP strains carried blaSHV gene, 29 strains (76.3%) carried blaTEM gene, and 26 strains (68.4%) carried blaCT-M gene. 7 strains (18.4%) among the 38 CRKP strains carried blaDHA-1 gene. 15 strains (39.5%) in 38 CRKP strains lost two fenestra proteins, ompK35 and ompK36, and the rest 23 strains carried ompK36 genes. 38 CRKP strains were divided into five kinds of ST types, with ST11 type as the most (86.8%, 33/38). The rest of the ST types included 2 strains of ST23 (5.3%, 2/38), one strain of ST15, ST1373 and ST1415 (2.6%, 1/38).

Conclusions

CRKP resistance is severe, and the mechanism of drug resistance has become increasingly complex. Various ST types and resistance genes are related to CRKP. The clinical prevention and control work is imminent.

Keywords: Klebsiella pneumoniae; carbapenem; resistance

1 Introduction

Klebsiella pneumoniae is a significant enterobacteriaceae in hospitals and community acquired infection that can lead to a variety of infections, such as the respiratory tract infection, urinary tract infection and blood infection. With the frequent use of antibiotics, infection caused by multiple drug resistance of gram-negative bacilli (MDRGN) is becoming an increasingly serious global problem. Meanwhile, with the increasing isolating rate of carbapenem-resistant Klebsiella pneumoniae, infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) have drawn much more attention. The resistance mechanism of CRKP is complex, and is possibly related to the production of carbapenemases, excessive expression of plasmid type AmpC enzyme and loss of fenestra proteins, quantity descent, loss or decreased affinity of carbapenem high affinity site PBP2, etc. [1, 2]. In recent years, CRKP was reported in many countries. Molecular epidemiology data based on multiple locus sequence typing (MLST) showed the variety of Klebsiella pneumoniae ST type [3]. Various reports suggested that ST type was related to drug resistance of strains. Such as, Klebsiella pneumoniae ST258 type is the most common carbapenem resistant ST type in United States and Greece [4, 5]. Recently, a Russia study also showed that ST340 type was related to the Klebsiella pneumoniae that produces NDM-1 carbapenem [6].

In China, CHINET resistance monitoring showed that the number of carbapenem-resistant enterobacteriaceae (CRE) increased year by year, of which CRKP occupied the most important proportion (64.2%) [7]. A report in 2007 discovered carbapenem that produced KPC-type 2 enzyme in Zhejiang province [8]. Since after, strains produce KPC-type 2 enzyme have been continuously detected and reported [1, 9, 10]. To understand the epidemiological characteristics of CRKP infections in our hospital, 38 CRKP strains isolated from our hospital in 2015 was investigated to verify its resistant properties and molecular epidemiological characteristics.

2 Methods

2.1 Strains

38 isolated CRKP strains were collected from clinical specimens in our hospital in 2015 without repeated isolates, including 28 strains from the intensive care unit, 5 strains from surgery department, 5 strains from medicine department; 22 strains isolated from sputum specimens, 10 strains from urine, 3 strains from blood, 2 strains from pyogenic fluid and 1 strain from ascites; 4 strains from patients aged 0-44, 12 strains from 45-59, and 22 strains from over 60. CRKP was defined when the strain was resistant to either meropenem or imipenem. Quality control strains were Escherichia coli ATCC 25922 (obtained from national center for clinical laboratories), produce KPC-2 enzyme Klebsiella pneumoniae (provided by professor Zhang Rong, Ph.D. of second affiliated hospital of Zhejiang university), produce IMI-1 enzyme Enterobacter cloacae (provided by professor Me-deiros, Ph.D. of American AA), Klebsiella pneumoniae ATCC 700603 and Klebsiella pneumoniae produce IMP-4 enzyme, SHV-3 enzyme and TEM-5 enzyme (provided by Jcoby, Ph.D. of GA, USA).

2.2 Reagents and instruments

Blood bacteria enrichment medium, blood agar plate, M-H agar and M-H broth were purchased for Hangzhou Tianhe Microorganism Reagents Company. Tested antimicrobial agents included cefazolin, cefepime, cefotaxime, cefoxitin, ampicillin, piperacillin/tazobactam, amoxicillin clavulanate, meropenem, imipenem, amikacin, tetracycline, ciprofloxacin, trimethoprim–sulfamethoxazole, tigecycline (Oxoid, British). The PCR detection kits and DNA marker were from Beijing Tiangen Company. Ethylenediaminetetraacetic acid (EDTA), Tris, ethidium bromide and agarose were for Shanghai Shenggong Company. MicroScanWalkAway 40 Plus Microbiology System (Siemens, Newark, DE, USA). SP1000 PCR amplification instrument (Bio-Rad Company, USA), DYY-III electrophoresis apparatus (Beijing Liuyi Instrument Factory), Tanon1600 gel imaging system (Shanghai Tianneng Company).

2.3 Bacteria identification and drug susceptibility test

Strains were identified at species level by the Siemens MicroScan WalkAway 40 Plus Microbiology System. Antimicrobial susceptibility was determined by Kirby-Bauer disk diffusion test. Results were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) 2015 guidelines [11]. Results of tigecycline were interpreted according to the breakpoint approved by the US Food and Drug Administration (FDA) [12].

2.4 DNA template preparation

Chromosome DNA of experimental strains was extracted using thermal cracking method. Experimental strains were inoculated to 5 ml nutrient broth, and cultured in 37°C for 6 hours, then centrifuged at 10000 RPM for 5 min and the supernatant was discarded. 1 ml saline was added and vibrated to suspend bacteria, then centrifuged at 10000 RPM for 5 min and the supernatant was discarded. 100 ml sterile distilled water was added to the precipitation and vibrated to suspend bacteria. After 10°C water bathing for 10 minutes and 10000 RPM centrifuging for 5 minutes, the supernatant was the template DNA for PCR amplification.

2.5 Resistant gene detection

According to references [13, 14, 15, 16], resistance genes related to carbapenemases class A (GES, IMI, KPC, NMC and SME), class B (IMP, VIM, GIM, SPM, SIM and NDM) and class D (OXA), ESBLs (SHV, TEM and CTX - M), AmpC β-lactamases (LAT, ACT, CMY and DHA) and fenestra proteins (ompK35 and ompK36) of the bacterial strains were detected. Primers were synthesized by Shanghai Shenggong Biological Engineering Technology Service co., LTD. PCR amplification system: upstream and downstream primers each 2 μl, 2xTaq DNA Master Mix 20μl, ddH2O 14μl, template 2 μl, total reaction volume 40 μl. PCR amplification parameters: 95°C pre degenerated for 5 min; then 35 cycles of 9°C degenerated for 10 s, 50-62°C annealed for 20s, followed by 72°C extended for 20 s; at last, 72°C extended for 40s. Anneal temperature of each primer was determined according to the melting temperature (Tm, Tm+ 5°C). Amplification products were electrophoresed using 1.5% agarose gel with ethidium bromide (0.5 μg/ml), and ultraviolet light was used to observe results. Products of PCR amplification positive strains were sent to Shanghai Shenggong Biological Engineering Technology Service co., LTD., for sequencing after purification. Nucleotide sequence analysis was performed by BLAST to identify genes.

2.6 MLST analysis

Seven housekeeping genes (rpoB, gapA, MDH, pgi, phoE, infB, tonB), PCR amplification primer sequences and the PCR reaction parameters were from website (http://www.pasteur.fr/mlst/) Total PCR reaction volume was 50μl, including upstream and downstream primers each 2 μl, 2x Taq DNA Master Mix 25 μl, template 2 μl and sterile ddH2O 19 μl. Amplification products were electrophoresed using 20 g/L agarose gel with ethidium bromide (0.5 μg/ml), and ultraviolet light was used to observe results. Products of PCR amplification positive strains were sent to Shanghai Shenggong Biological Engineering Technology Service co., LTD., for sequencing. Sequencing results were compared using the database (http://www.pasteur.fr/mlst/) Alleles of each strain were obtained to determine its MLST type. After setting the 6 genes of the 7 housekeeping genes as the same clone group, eBURST version 3.0 software was used for correlation analysis for each strain sequence type (ST) in strain clones complex (CC).

2.7 Data process and statistical analysis

After data were derived, EXCEL2007 was used for sorting. SPSS software (version 19.0) was used for statistics. Chi-square or Fisher’s accurate inspection was used to compare the difference between the groups. P < 0.05 was considered statistically significant.

Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the authors' institutional review board or equivalent committee.

Informed consent: Informed consent has been obtained from all individuals included in this study.

3 Results

3.1 Antimicrobial susceptibilities of CRKP strains

All 38 experimental strains were resistant to β-lactam antibiotics, β-lactam antibiotics/β-lactamase inhibitors and ciprofloxacin. The resistance rate was more than 70.0%.Ampicillin was the highest among them (100.0%). 37 strains of 38 experimental strains were resistant to imipenem, the rest 1 strain was sensitive to imipenem, but resistant to meropenem, so all 38 strains in the study were CRKP strains. All 38 experimental strains showed little resistance to tetracycline, amikacin and compound sulfanilamide, the rates of which were between 31.6~55.3%, and they were not resistant to tigecycline at all. Resistance of experiment strains is shown in Table 1.

Table 1

Antimicrobial resistance of 38 carbapenem-resistant Klebsiella pneumoniaee (CRKP) strains

DepartmentSpecimensAge
Antibiotics

ICU

(n=28)

Surgery

(n=5)

Medicine

(n=5)

P Value

Sputum

(n=22)

Urine

(n=10)

Others

(n=6)

P Value

0-44

(n=4)

45-59

(n=12)

>60

(n=22)

P Value

Total (%)

(n=38)

Tigecycline000-000-000-0 (0)
Tetracycline6330.0795520.3010480.51912 (31.6)
Compound sulfonamides8320.4037420.8940580.41513 (34.2)
Amikacin15150.05511640.73425140.45421 (55.3)
Cefoxitin18450.38513950.17537170.53027 (71.1)
Ciprofloxacin22550.459171050.26538210.04432 (84.2)
Piperacillin/Tazobactam27330.01220760.251410191.00033 (86.8)
Meropenem27350.08121860.223410210.48935 (92.1)
Cefazolin27440.16421860.223411201.00035 (92.1)
Cefotaxime26450.61220961.000410210.48935 (92.1)
Amoxicillin/Clavulanic acid28540.26322960.421412211.00037 (97.4)
Cefepime27551.000211061.000411220.42137 (97.4)
Imipenem28540.26322960.421412211.00037 (97.4)
Ampicillin2855-22106-41222-38 (100.0)

  1. Note: other specimens include ascites, fester and blood.

3.2 Resistance genes test

Results of CRKP resistant gene detection showed that 34 strains (89.5%) among the 38 CRKP strains carried blaKPC-2 gene, and 3 strains (7.9%) carried blaIMP-4 gene. No resistant gene was found in the rest CRKP strains. 36 strains (94.7%) among the 38 CRKP strains carried carbapenem resistant gene, and there was one in the 36 carried both blaKPC-2 gene and blaIMP-4 gene. Results of ESBLs showed that 36 strains (94.7%) among the 38 CRKP strains carried blaSHV gene, and there were 32 strains in the 36 carried blaSHV-11 gene, 3 strains carried blaSHV-142 gene, 1 strain carried blaSHV-1 gene; 29 strains (76.3%) carried blaTEM gene, and there were 15 strains of the 29 carried blaTEM-1 gene, 9 strains carried blaTEM-135 gene, 5 strains carried blaTEM-198 gene; and 26 strains (68.4%) carried blaCT-M gene, there were 14 strains of the 26 carried blaCTX-M-14 gene, 8 strains carried blaCTX-M-65 gene, 2 strains carried both blaCTX-M-15 gene and blaCTX-M-3 gene. No ESBLs resistant gene was found in the rest CRKP strains. Results of AmpC enzyme showed that 7 strains (18.4%) among the 38 CRKP strains carried blaDHA-1 gene, and no AmpC enzyme resistant gene was found in the rest CRKP strains. 15 strains (39.5%) in 38 CRKP strains lost two fenestra proteins, ompK35 and ompK36, and the rest 23 strains carried ompK36 genes. In addition, 13 strains (34.2%) carried carbapenem gene and two fenestra proteins lost. And no fenestra protein lost was found in the non-carbapenem-resistant strains.

The blue circle denotes the primary founder. The yellow circle denotes the subgroup founder. The pink number denotes the ST type exists in both experimental strains and strains in Zhejiang province. The green numbers denote the ST type only exists in the experimental strains, and black numbers are the ST types of Klebsiella pneumoniae exist in Zhejiang province.

3.3 MLST analysis results

38 CRKP strains were analyzed by MLST, and five ST types were detected.ST11(86.8%, 33/38)was the most frequent ST type. The rest of the ST types included 2 strains of ST23 (5.3%, 2/38), 1 strain of ST15, ST1373 and ST1415 (2.6%, 1/38). Among 33 strains of ST11, 31 strains (93.9%) carried blaKPC-2 gene. eBURST version 3.0 software was used to compare each strain sequence type (ST) with the information in database (http://www.pasteur.fr/mlst/) The cluster analysis full view diagram of 38 CRKP strains comparing with ST classification of Klebsiella pneumoniae in Zhejiang province is shown in Figure 1.

Figure 1 The cluster analysis full view diagram of 38 CRKP strains comparing with ST classification of Klebsiella pneumoniae in Zhejiang province.
Figure 1

The cluster analysis full view diagram of 38 CRKP strains comparing with ST classification of Klebsiella pneumoniae in Zhejiang province.

4 Discussion

Carbapenems is the first choice for the treatment of multi-drug resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae that produce ultra broad-spectrum β-lactamase (ESBLs) and AmpC enzyme. At times, it may be the only available antibiotic. The emergence of CRE limits the application of carbapenem in some patients with severe infections, which may lead to the raise of the fatality rate of infection. In recent 10 years, infections caused by CRE increased significantly. There are reports of CRE in many countries, such as Israel, Greece, Turkey, Egypt, Lebanon and Saudi Arabia [17, 18, 19]. Therefore, CRE has been transformed from the original scattered status into the international popular drug resistant strains. CHINET bacterial drug resistance monitoring network in China showed that clinical separated CRE strains from enterobacteriaceae previously were Klebsiella species, mainly the Klebsiella pneumoniae [20]. Klebsiella pneumoniae is one of the most common clinical hospital infection bacteria. The emergence of CRKP, with its complex mechanism, caused wide spread, and which has been one of the most difficult problems in clinical infection therapy. Therefore, this study isolated CRKP in our hospital in the latest year for resistance and molecular epidemiological study, which provides the basis for clinical treatment, prevention and control.

Results of this study showed that 38 CRKP strains were mainly from the intensive care unit, mainly older patients, and mostly isolated from sputum specimens. This may be related to the immunity state of patients, the long-time hospital treatment and some invasive operations. Susceptibility test results of 38 CRKP strains to 14 antimicrobial drugs showed that those strains were sensitive to tigecycline, tetracycline, amikacin and compound sulfanilamide, while they were highly resistant to most of the clinical commonly used antibiotics, especially the β-lactam antibiotics, except forcefoxitin. The resistant rates were above 90.0%.

This result was consistent with CHINET bacterial drug resistance monitoring network data in our country [20]. Besides, several studies have demonstrated that the polymyxin B, polymixin E, tigecycline and aminoglycoside antibiotics are sensitive to CRKP and thought to be the antibiotics of choice for CRKP, which are the last defense line to CRKP [21]. In this study, resistance rates of 38 experimental strains to tetracycline, amikacin and compound sulfanilamide were low, and those strains were not resistant to tigecycline at all. Therefore, in clinical treatment of CRKP, these antibiotics should be readily accessible, to avoid unnecessary new resistance by paying attention to identifying the pathogenic bacteria. It is worth noting that CRKP were not resistant to tigecycline, a glycyl tetracycline, which undoubtedly brought good news for clinical treatment. However, the urinary tract permeability of tigecycline was poor. After tigecycline enters the bloodstream, it quickly distributes. So the tigecycline application value of blood infection and urinary tract infection is questionable [22]. Considering the limitation of the treatment of urinary tract infection with tigecycline, more attention should be paid to the prevention, isolation and clinical medication treatment.

Results of CRKP resistant gene detection showed that 36 strains (94.7%) among the 38 CRKP strains carried carbapenem resistant gene, and there was one in the 36 carried both blaKPC-2 gene and blaIMP-4 gene. Thus, as previously reported, carbapenem resistant gene is the main cause of Klebsiella pneumoniae resistant to carbapenem antibiotics [23]. 15 strains (39.5%) in 38 CRKP strains lost two fenestra proteins, ompK35 and ompK36, and two strains without carbapenem resistant gene lost all fenestra proteins. The lack of either OmpK35 or OmpK36 only caused reduced susceptibility to cefoxitin and cefotaxime, but was still sensitive to carbapenem. Only lack of both can lead to lower sensitivity to imipenem and meropenem [24]. Because of this phenomenon, the two strains without carbapenem resistant gene were still resistant to carbapenem. It is worth noting that in this study, 13 strains (34.2%) carried carbapenem resistant gene and two fenestra proteins lost, suggesting that resistance is generally widespread. Meanwhile, 38 CRKP strains all had ESBLs resistant gene, suggesting that resistance mechanism is increasingly complex, thus clinical prevention and control work is imminent.

According to the eBURST clustering analysis diagram, ST11 type Klebsiella pneumoniae is one of the clone strains of Klebsiella pneumoniae in Zhejiang province. At the same time, some studies showed that in Asian countries, ST11 type had become the main clone strain that carried blaKPC and blaNDM, and also related to carbapenem antibiotic resistance [25, 26, 27, 28, 29]. Results of MLST classification of 38 CRKP strains showed that ST11 type strain was the most (86.8%, 33/38). Among them, 31 strains (93.9%) carry blaKPC-2 gene. These statistics are similar in Asia. In addition, only one strain was with ST15, ST23, ST1373 and ST1415 in this research. According to the clustering analysis diagram, ST15, ST23 and ST1373, as well as ST352, ST1417 and ST17 were regarded as one clone, while ST1373 was an independent clone strain, suggesting that the carbapenem resistance related ST type could be evolved by existing strains, and could also be produced by new clone strains.

The abuse of antibiotics is the basis of appearance and popularity of CRKP. Quick detection method of CRE is limited in clinical currently, thus the relevant prevention and control work are not timely. Effective drugs used to treat infections caused by CRKP are limited, causing the epidemic spread of drug resistant strains. Various CRKP ST types are related to resistance gene, which provides a reliable basis for the prevention and control work in clinical treatment. Effective intervention and control measures should be taken urgently, to curb the spread caused by drug resistant strains, and reduce the currently high resistance rate [20].

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  1. Funding: This work was supported by the Medical Science Foundation of Nanjing Military Command (No. 10Z037)

  2. Conflict of interest: The authors report no conflicts of interest in this work.

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Received: 2016-08-17
Accepted: 2018-06-08
Published Online: 2018-10-16

© 2018 Di Lin et al., published by De Gruyter

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

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  20. Effects of arginine vasopressin on migration and respiratory burst activity in human leukocytes
  21. Associations of diabetic retinopathy with retinal neurodegeneration on the background of diabetes mellitus. Overview of recent medical studies with an assessment of the impact on healthcare systems
  22. Pituitary dysfunction from an unruptured ophthalmic internal carotid artery aneurysm with improved 2-year follow-up results: A case report
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  24. Piercing and tattoos in adolescents: legal and medico-legal implications
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  26. Penile calciphylaxis in a patient with end-stage renal disease: a case report and review of the literature
  27. Serum CA72-4 as a biomarker in the diagnosis of colorectal cancer: A meta-analysis
  28. Association between uric acid and metabolic syndrome in elderly women
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  30. MAPK pathway involved in epidermal terminal differentiation of normal human epidermal keratinocytes
  31. Association of central obesity with sex hormonebinding globulin: a cross-sectional study of 1166 Chinese men
  32. Successful endovascular therapy in an elderly patient with severe hemorrhage caused by traumatic injury
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  34. Related factors of early mortality in young adults with cerebral hemorrhage
  35. Growth suppression of glioma cells using HDAC6 inhibitor, tubacin
  36. Post-stroke upper limb spasticity incidence for different cerebral infarction site
  37. The esophageal manometry with gas-perfused catheters
  38. MMP-2 and TIMP-2 in patients with heart failure and chronic kidney disease
  39. Genetic testing: ethical aspects
  40. Intervention for physician burnout: A systematic review
  41. The melanin-concentrating hormone system in human, rodent and avian brain
  42. Clinical effects of piribedil in adjuvant treatment of Parkinson’s Disease: A meta-analysis
  43. Identification of a novel BRAF Thr599dup mutation in lung adenocarcinoma
  44. Adrenal incidentaloma – diagnostic and treating problem – own experience
  45. Common illnesses in tropical Asia and significance of medical volunteering
  46. Genetic risk in insurance field
  47. Genetic testing and professional responsibility: the italian experience
  48. The mechanism of mitral regurgitant jets identified by 3-dimensional transesophageal echocardiography
  49. Control of blood pressure and cardiovascular outcomes in type 2 diabetes
  50. Pseudomesotheliomatous primary squamous cell lung carcinoma: The first case reported in Turkey and a review of the literature
  51. Diagnostic efficacy of serum 1,3-β-D-glucan for invasive fungal infection: An update meta-analysis based on 37 case or cohort studies
  52. GPER was associated with hypertension in post-menopausal women
  53. Metabolic activity of sulfate-reducing bacteria from rodents with colitis
  54. Association of miRNA122 & ADAM17 with lipids among hypertensives in Nigeria
  55. The efficacy and safety of enoxaparin: a meta-analysis
  56. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis
  57. Thresholding for medical image segmentation for cancer using fuzzy entropy with level set algorithm
  58. Sleep deprivation in Intensive Care Unit – systematic review
  59. Benefits of computed tomography in reducing mortality in emergency medicine
  60. Ipragliflozin ameliorates liver damage in non-alcoholic fatty liver disease
  61. Limits of professional competency in nurses working in Nicu
  62. MDA-19 suppresses progression of melanoma via inhibiting the PI3K/Akt pathway
  63. The effect of smoking on posttraumatic pseudoarthrosis healing after internal stabilization, treated with platelet rich plasma (PRP)
  64. Partial deletion of the long arm of chromosome 7: a case report
  65. Meta-analysis of PET/CT detect lymph nodes metastases of cervical cancer
  66. High Expression of NLRC5 is associated with prognosis of gastric cancer
  67. Is monitoring mean platelet volume necessary in breast cancer patients?
  68. Resectable single hepatic epithelioid hemangioendothelioma in the left lobe of the liver: a case report
  69. Epidemiological study of carbapenem-resistant Klebsiella pneumoniae
  70. The CCR5-Delta32 genetic polymorphism and HIV-1 infection susceptibility: a meta-analysis
  71. Phenotypic and molecular characterisation of Staphylococcus aureus with reduced vancomycin susceptibility derivated in vitro
  72. Preliminary results of Highly Injectable Bi-Phasic Bone Substitute (CERAMENT) in the treatment of benign bone tumors and tumor-like lesions
  73. Analysis of patient satisfaction with emergency medical services
  74. Guillain-Barré syndrome and Low back pain: two cases and literature review
  75. HELLP syndrome complicated by pulmonary edema: a case report
  76. Pharmacokinetics of vancomycin in patients with different renal function levels
  77. Recurrent chronic subdural hematoma: Report of 13 cases
  78. Is awareness enough to bring patients to colorectal screening?
  79. Serum tumor marker carbohydrate antigen 125 levels and carotid atherosclerosis in patients with coronary artery disease
  80. Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review
  81. High expression levels of fascin-1 protein in human gliomas and its clinical relevance
  82. Thromboembolic complications following tissue plasminogen activator therapy in patients of acute ischemic stroke - Case report and possibility for detection of cardiac thrombi
  83. The effects of gastrointestinal function on the incidence of ventilator-associated pneumonia in critically ill patients
  84. A report of chronic intestinal pseudo-obstruction related to systemic lupus erythematosus
  85. Risk model in women with ovarian cancer without mutations
  86. Direct oral anticoagulants and travel-related venous thromboembolism
  87. How bispectral index compares to spectral entropy of the EEG and A-line ARX index in the same patient
  88. Henoch-schonlein purpura nephritis with renal interstitial lesions
  89. Cardiovascular risk estimated by UKPDS risk engine algorithm in diabetes
  90. CD5 and CD43 expression are associate with poor prognosis in DLBCL patients
  91. Combination of novoseven and feiba in hemophiliac patients with inhibitors
https://doi.org/10.1515/med-2018-0070
Schlagwörter für diesen Artikel
Klebsiella pneumoniae; carbapenem; resistance
Creative Commons
BY-NC-ND 4.0

Artikel in diesem Heft

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  2. Cleidocranial dysplasia-dental disorder treatment and audiology diagnosis
  3. A hybrid neural network – world cup optimization algorithm for melanoma detection
  4. Early administration of venovenous extracorporeal life support for status asthmaticus during anaesthetic induction: case report and literature review
  5. Assessment of maximal isometric hand grip strength in school-aged children
  6. Evaluation of a neurokinin-1 antagonist in preventing multiple-day cisplatin-induced nausea and vomiting
  7. Value of continuous video EEG and EEG responses to thermesthesia stimulation in prognosis evaluation of comatose patients after cardiopulmonary resuscitation
  8. Platelet-rich plasma protects HUVECs against oX-LDL-induced injury
  9. Pharmacoeconomics of three therapeutic schemes for anti-tuberculosis therapy induced liver injury in China
  10. Small-cell lung cancer presenting as fatal pulmonary hemorrhage
  11. Correlation of retinopathy of prematurity with bronchopulmonary dysplasia
  12. Prognosis of treatment outcomes by cognitive and physical scales
  13. The efficacy of radiofrequency hyperthermia combined with chemotherapy in the treatment of advanced ovarian cancer
  14. Arcuate Fasciculus in Autism Spectrum Disorder Toddlers with Language Regression
  15. Aesthetic dental procedures: legal and medico-legal implications
  16. Blood transfusion in children: the refusal of Jehovah’s Witness parents’
  17. Burnout among anesthetists and intensive care physicians
  18. Relationship of HS CRP and sacroiliac joint inflammation in undifferentiated spondyloarthritis
  19. Ethical and legal issues in gestational surrogacy
  20. Effects of arginine vasopressin on migration and respiratory burst activity in human leukocytes
  21. Associations of diabetic retinopathy with retinal neurodegeneration on the background of diabetes mellitus. Overview of recent medical studies with an assessment of the impact on healthcare systems
  22. Pituitary dysfunction from an unruptured ophthalmic internal carotid artery aneurysm with improved 2-year follow-up results: A case report
  23. Effectiveness of treatment with endostatin in combination with emcitabine, carboplatin, and gemcitabine in patients with advanced non-small cell lung cancer: a retrospective study
  24. Piercing and tattoos in adolescents: legal and medico-legal implications
  25. The central importance of information in cosmetic surgery and treatments
  26. Penile calciphylaxis in a patient with end-stage renal disease: a case report and review of the literature
  27. Serum CA72-4 as a biomarker in the diagnosis of colorectal cancer: A meta-analysis
  28. Association between uric acid and metabolic syndrome in elderly women
  29. Distinct expression and prognostic value of MS4A in gastric cancer
  30. MAPK pathway involved in epidermal terminal differentiation of normal human epidermal keratinocytes
  31. Association of central obesity with sex hormonebinding globulin: a cross-sectional study of 1166 Chinese men
  32. Successful endovascular therapy in an elderly patient with severe hemorrhage caused by traumatic injury
  33. Inflammatory biomarkers and risk of atherosclerotic cardiovascular disease
  34. Related factors of early mortality in young adults with cerebral hemorrhage
  35. Growth suppression of glioma cells using HDAC6 inhibitor, tubacin
  36. Post-stroke upper limb spasticity incidence for different cerebral infarction site
  37. The esophageal manometry with gas-perfused catheters
  38. MMP-2 and TIMP-2 in patients with heart failure and chronic kidney disease
  39. Genetic testing: ethical aspects
  40. Intervention for physician burnout: A systematic review
  41. The melanin-concentrating hormone system in human, rodent and avian brain
  42. Clinical effects of piribedil in adjuvant treatment of Parkinson’s Disease: A meta-analysis
  43. Identification of a novel BRAF Thr599dup mutation in lung adenocarcinoma
  44. Adrenal incidentaloma – diagnostic and treating problem – own experience
  45. Common illnesses in tropical Asia and significance of medical volunteering
  46. Genetic risk in insurance field
  47. Genetic testing and professional responsibility: the italian experience
  48. The mechanism of mitral regurgitant jets identified by 3-dimensional transesophageal echocardiography
  49. Control of blood pressure and cardiovascular outcomes in type 2 diabetes
  50. Pseudomesotheliomatous primary squamous cell lung carcinoma: The first case reported in Turkey and a review of the literature
  51. Diagnostic efficacy of serum 1,3-β-D-glucan for invasive fungal infection: An update meta-analysis based on 37 case or cohort studies
  52. GPER was associated with hypertension in post-menopausal women
  53. Metabolic activity of sulfate-reducing bacteria from rodents with colitis
  54. Association of miRNA122 & ADAM17 with lipids among hypertensives in Nigeria
  55. The efficacy and safety of enoxaparin: a meta-analysis
  56. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis
  57. Thresholding for medical image segmentation for cancer using fuzzy entropy with level set algorithm
  58. Sleep deprivation in Intensive Care Unit – systematic review
  59. Benefits of computed tomography in reducing mortality in emergency medicine
  60. Ipragliflozin ameliorates liver damage in non-alcoholic fatty liver disease
  61. Limits of professional competency in nurses working in Nicu
  62. MDA-19 suppresses progression of melanoma via inhibiting the PI3K/Akt pathway
  63. The effect of smoking on posttraumatic pseudoarthrosis healing after internal stabilization, treated with platelet rich plasma (PRP)
  64. Partial deletion of the long arm of chromosome 7: a case report
  65. Meta-analysis of PET/CT detect lymph nodes metastases of cervical cancer
  66. High Expression of NLRC5 is associated with prognosis of gastric cancer
  67. Is monitoring mean platelet volume necessary in breast cancer patients?
  68. Resectable single hepatic epithelioid hemangioendothelioma in the left lobe of the liver: a case report
  69. Epidemiological study of carbapenem-resistant Klebsiella pneumoniae
  70. The CCR5-Delta32 genetic polymorphism and HIV-1 infection susceptibility: a meta-analysis
  71. Phenotypic and molecular characterisation of Staphylococcus aureus with reduced vancomycin susceptibility derivated in vitro
  72. Preliminary results of Highly Injectable Bi-Phasic Bone Substitute (CERAMENT) in the treatment of benign bone tumors and tumor-like lesions
  73. Analysis of patient satisfaction with emergency medical services
  74. Guillain-Barré syndrome and Low back pain: two cases and literature review
  75. HELLP syndrome complicated by pulmonary edema: a case report
  76. Pharmacokinetics of vancomycin in patients with different renal function levels
  77. Recurrent chronic subdural hematoma: Report of 13 cases
  78. Is awareness enough to bring patients to colorectal screening?
  79. Serum tumor marker carbohydrate antigen 125 levels and carotid atherosclerosis in patients with coronary artery disease
  80. Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review
  81. High expression levels of fascin-1 protein in human gliomas and its clinical relevance
  82. Thromboembolic complications following tissue plasminogen activator therapy in patients of acute ischemic stroke - Case report and possibility for detection of cardiac thrombi
  83. The effects of gastrointestinal function on the incidence of ventilator-associated pneumonia in critically ill patients
  84. A report of chronic intestinal pseudo-obstruction related to systemic lupus erythematosus
  85. Risk model in women with ovarian cancer without mutations
  86. Direct oral anticoagulants and travel-related venous thromboembolism
  87. How bispectral index compares to spectral entropy of the EEG and A-line ARX index in the same patient
  88. Henoch-schonlein purpura nephritis with renal interstitial lesions
  89. Cardiovascular risk estimated by UKPDS risk engine algorithm in diabetes
  90. CD5 and CD43 expression are associate with poor prognosis in DLBCL patients
  91. Combination of novoseven and feiba in hemophiliac patients with inhibitors
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