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Tuon FF, Zequinao T, da Silva MS, Silva KO. eHealth and mHealth in Antimicrobial Stewardship to Reduce Mortality in Empirical Antimicrobial Therapy and a Systematic Review with a Meta-Analysis of Adequate Therapy. Infect Dis Rep 2024; 16:707-723. [PMID: 39195005 DOI: 10.3390/idr16040054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/29/2024] Open
Abstract
The urgent requirement for swift diagnostic methods in pathogen identification and antimicrobial susceptibility testing is emphasized by rising bacterial resistance and limited treatment options, which are particularly critical in sepsis management. The shift from traditional phenotype-based methods to rapid molecular and mass spectrometry techniques has significantly reduced result turnaround times, enhancing patient outcomes. In this systematic review with meta-analysis, the aspects of correct empirical antimicrobial therapy are evaluated to determine their impact on mortality. We performed a systematic review and meta-analysis on EMBASE, the Cochrane Library, Web of Science, and MEDLINE. Studies evaluating mortality associated with empirical adequate and inadequate therapy in different sites of infection were included. Outcomes included clinical cures in microbiologically evaluable patients. Among the sites of infection, the most studied were bloodstream infections (n = 9), followed by respiratory tract infections (n = 5), intra-abdominal infections (n = 5), and urinary tract infections (evaluated by 3 studies). Inadequate therapy was associated with an increase in mortality between 11 and 68%. Technologies to speed up pathogen identification are extremely necessary to reduce mortality.
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Affiliation(s)
- Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Tiago Zequinao
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Marcelo Silva da Silva
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Kleber Oliveira Silva
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
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de Miguel-Palacio M, González-Castillo AM, Membrilla-Fernández E, Pons-Fragero MJ, Pelegrina-Manzano A, Grande-Posa L, Morera-Casaponsa R, Sancho-Insenser JJ. Impact of empiric antibiotic therapy on the clinical outcome of acute calculous cholecystitis. Langenbecks Arch Surg 2023; 408:345. [PMID: 37644336 PMCID: PMC10465626 DOI: 10.1007/s00423-023-03063-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Although mortality and morbidity of severe acute calculous cholecystitis (ACC) are still a matter of concern, the impact of inadequate empirical antibiotic therapy has been poorly studied as a risk factor. The objective was to assess the impact of the adequacy of empirical antibiotic therapy on complication and mortality rates in ACC. METHODS This observational retrospective cohort chart-based single-center study was conducted between 2012 and 2016. A total of 963 consecutive patients were included, and pure ACC was selected. General, clinical, postoperative, and microbiological variables were collected, and risk factors and consequences of inadequate treatment were analyzed. RESULTS Bile, blood, and/or exudate cultures were obtained in 76.3% of patients, more often in old, male, and severely ill patients (P < 0.001). Patients who were cultured had a higher overall rate of postoperative complications (47.4% vs. 29.7%; P < 0.001), as well as of severe complications (11.6% vs. 4.7%; P = 0.008). Patients with positive cultures had more overall complications (54.8% vs. 39.6%; P = 0.001), more severe complications (16.3% vs. 6.7%; P = 0.001), and higher mortality rates (6% vs. 1.9%; P = 0.012). Patients who received inadequate empirical antibiotic therapy had a fourfold higher mortality rate than those receiving adequate therapy (n = 283; 12.8% vs. 3.4%; P = 0.003). This association was especially marked in severe ACC TG-III patients (n = 132; 18.2 vs. 5.1%; P = 0.018) and remained a predictor of mortality in a binary logistic regression (OR 4.4; 95% CI 1.3-15.3). CONCLUSION Patients with positive cultures developed more complications and faced higher mortality. Adequate empirical antibiotic therapy appears to be of paramount importance in ACC, particularly in severely ill patients.
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Affiliation(s)
- Maite de Miguel-Palacio
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain.
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - Ana-María González-Castillo
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Estela Membrilla-Fernández
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - María-José Pons-Fragero
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Amalia Pelegrina-Manzano
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Luis Grande-Posa
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Juan-José Sancho-Insenser
- Department of Surgery, Autonomous University of Barcelona, Barcelona, Spain
- Department of General Surgery, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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López GAM, Rodríguez LFC, Fandiño LCS, Lasso AD, Granados JPA, Salazar YID, Pereira KA, Velásquez JP, Luna JAC, Trujillo CHS. Effectiveness of Five Antibiotic Regimens for the Treatment of Intra-Abdominal Infection in Bogotá. Surg Infect (Larchmt) 2022; 23:933-939. [PMID: 36472509 DOI: 10.1089/sur.2022.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Intra-abdominal infection (IAI) results in prolonged in-hospital length-of-stay, critical care unit requirements, and multiple surgical procedures. Several antimicrobial agents are available for treatment of IAI. In Colombia, there are no data on the comparative effectiveness of the different regimens used. Patients and Methods: A multicenter retrospective cohort study was completed in four third-level hospitals by comparing treatment effectiveness of five different antibiotic protocols (ampicillin-sulbactam, clindamycin-amikacin, piperacillin-tazobactam, amikacin-metronidazole, and cefuroxime-metronidazole) in patients with a diagnosis of IAI. Analysis was based on a composed outcome of therapeutic failure (change of antibiotic because of no clinical improvement, requirement of surgical re-intervention, post-operative infection, change of antibiotic because of antimicrobial resistance, and in-hospital mortality). Association of each antibiotic protocol to therapeutic failure was assessed through logistic regression analysis. Results: Five hundred ninety-three individuals were included. Two hundred twenty-nine were prescribed ampicillin-sulbactam; 170, clindamycin-amikacin; 77, amikacin-metronidazole; 83, piperacillin-tazobactam; and 34, cefuroxime-metronidazole. Therapeutic failure rate was 22%. Multivariable analysis showed none of the evaluated antibiotic protocols had an association with the primary outcome. Variables having an association for higher risk were age >70 years old (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.04-4.18); complicated IAI (OR, 3.36; 95% CI, 1.4-8.07); and World Society of Emergency Surgery (WSES) Sepsis Severity Score (OR, 1.31; 95% CI, 1.18-1.45). Adequate source control (OR, 0.16; 95% CI, 0.05-0.45) and hospitalization at Health Center 2 (OR, 0.30; 95% CI, 0.14-0.63) were identified as protective factors. Conclusions: There are no differences between the rate of therapeutic failure among the different antibiotic protocols evaluated. This outcome depends heavily on risk factors related to disease severity when surgical intervention occurs.
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Wang Y, Zhang X, Wang X, Lai X. Appropriateness of Empirical Fluoroquinolones Therapy in Patients Infected with Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa: The Importance of the CLSI Breakpoints Revision. Infect Drug Resist 2021; 14:3541-3552. [PMID: 34511945 PMCID: PMC8418362 DOI: 10.2147/idr.s329477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/18/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose Empirical antibiotic therapy should follow the local bacterial susceptibility, and the breakpoints revisions of the antimicrobial susceptibility testing can reflect the changes in the antimicrobial susceptibility of bacteria. This study aimed to analyze whether the changes in the antimicrobial susceptibility to antibiotics caused by the breakpoint revision will affect the empirical antibiotic therapy and its appropriateness. Patients and Methods A retrospective study was conducted among 831 hospitalized patients infected by Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa from April 10, 2018, to April 11, 2020. We evaluated the appropriateness of empirical therapy based on the antimicrobial susceptibility testing results. The rate of empirical use and appropriateness of fluoroquinolones was calculated, and logistic regression was used to analyze influencing factors of empirical use of fluoroquinolones. Results The susceptibility rate of the three bacteria to levofloxacin (50.78% vs 32.06%) and ciprofloxacin (48.45% vs 21.90%) was decreased (P<0.001), while the resistance rate to levofloxacin (45.74% vs 58.73%) and ciprofloxacin (46.90% vs 66.67%) was increased (P<0.001) after the breakpoints revision. The empirical usage rate of fluoroquinolones in patients infected with Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa was 20.94%, which was influenced by the breakpoint revision (P=0.022), age (P=0.007), and the department (P=0.006); the appropriateness rate was 28.74%, affected by the pathogenic bacteria (P=0.001) and multidrug-resistant microorganism (P=0.001), department (P=0.024), and the length of stay before the empirical therapy (P=0.016). Conclusion The susceptibility of bacteria to antibiotics has changed significantly after the breakpoint revision while the clinicians’ empirical therapy failure to change accordingly, which results in the decrease of the appropriateness of empirical use. It is enlightened that we should conduct more research to evaluate the rational use of antibiotics from the laboratory perspective and carry out interventions such as education and supervision to strengthen the collaboration between the microbiology laboratories and clinicians to improve the empirical antibiotic therapy and slow down the antimicrobial resistance.
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Affiliation(s)
- Ying Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, HuBei, People's Republic of China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, HuBei, People's Republic of China
| | - Xuemei Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, HuBei, People's Republic of China
| | - Xiaoquan Lai
- Department of Nosocomial Infection Management, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, HuBei, People's Republic of China
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Grotelüschen R, Heidelmann LM, Lütgehetmann M, Melling N, Reeh M, Ghadban T, Dupree A, Izbicki JR, Bachmann KA. Antibiotic sensitivity in correlation to the origin of secondary peritonitis: a single center analysis. Sci Rep 2020; 10:18588. [PMID: 33122689 PMCID: PMC7596236 DOI: 10.1038/s41598-020-73356-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022] Open
Abstract
Despite improvements in diagnosis, intensive-care medicine and surgical technique, the mortality of patients with secondary peritonitis is still high. Early and aggressive empiric antibiotic treatment has strong impact on the outcome. This retrospective study investigates bacterial and fungal pathogens and their antibiotic sensitivity in patients with secondary peritonitis. All patients that underwent emergency laparotomy due to secondary peritonitis at the Department of Surgery, University Medical Center Hamburg-Eppendorf between 2005 and 2015 were reviewed and overall 414 patients were included. We correlated the intra-abdominal localization of the organ perforation with intraoperative microbiological findings and corresponding sensitivities to relevant antibiotics. Overall, the most common findings were Escherichia coli (39%) and other Enterobacterica (24%). Depending on the location of the perforation, Cefuroxime/Metronidazole and Cefutaxime/Metronidazole were effective (based on in vitro susceptibility testing) in only 55–73% of the patients, while Meropenem/Vancomycin was able to control the peritonitis in more than 98% of the patients; independent of the location. Besides early source control, appropriate empiric treatment plays a pivotal role in treatment of secondary peritonitis. We are able to show that the frequently used combinations of second or third generation Cephalosporins with Metronidazole are not always sufficient, which is due to the biological resistance of the bacteria. Further clinical studies are needed to determine whether calculated use of broad-spectrum antibiotics with a sensitivity rate > 99%, such as Carbapenem plus Vancomycin, can improve overall survival rates in critically ill patients with secondary peritonitis.
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Affiliation(s)
- Rainer Grotelüschen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lena M Heidelmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Marc Lütgehetmann
- Institute for Medical Microbiology, Virology and Hygiene, Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Anna Dupree
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kai A Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Rickard J. Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What? Surg Infect (Larchmt) 2019; 20:192-196. [PMID: 30698510 DOI: 10.1089/sur.2018.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Rickard J, Ngarambe C, Ndayizeye L, Smart B, Riviello R, Majyambere JP, Ghebre RG. Antibiotic Use and Antimicrobial Resistance of Surgical Patients with Peritonitis at a Tertiary Referral Hospital in Rwanda. Surg Infect (Larchmt) 2018; 19:382-387. [PMID: 29621001 DOI: 10.1089/sur.2017.158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is growing recognition of the worsening problem of antibiotic resistance and the need for antibiotic stewardship in low-resource settings. The aim of this study was to describe antibiotic use and antimicrobial resistance in patients undergoing surgery for peritonitis at a Rwandan referral hospital. PATIENTS AND METHODS All surgical patients with peritonitis at a Rwandan referral hospital were enrolled. Prospective data were collected on epidemiology, clinical features, interventions, and outcomes. Antibiotic agents were prescribed and cultures were collected according to surgeon discretion. High risk for antibiotic treatment failure or death was defined as patients with severe sepsis, older than 70 years of age, tumor, or operating room delay more than 24 hours from hospital admission. Logistic regression was used to determine factors associated with high risk of antibiotic treatment failure or death. RESULTS Over a six-month period, 280 patients underwent operation for peritonitis; 79 patients were excluded because no infectious etiology was identified at operation. Data on antibiotic usage were available for 165 patients. The most common diagnoses were intestinal obstruction (n = 43) and appendicitis (n = 36). Most patients received antibiotic agents, the most of of which being third-generation cephalosporins (n = 149; 90%) and metronidazole (n = 140; 85%). The mean duration of antibiotics was 5.1 days (range: 0-14). Overall, 80 (54%) patients were high-risk for antibiotic treatment failure or death. Risk for antibiotic treatment failure or death was associated with localized peritonitis (p = 0.001) and high American Society of Anesthesiologist score (p = 0.003). Cultures were collected from 33 patients and seven patients had an organism isolated. Escherichia coli was identified in in five surgical specimens and two 2 urine cultures. All Escherichia coli specimens showed resistance to cephalosporins. CONCLUSIONS Broad antibiotic coverage with third-generation cephalosporins and metronidazole is common in Rwandan surgical patients with peritonitis. Areas for improvement should focus on choice and duration of antibiotic agents, tailored to underlying diagnosis and risk factors for antibiotic treatment failure or death. More data are needed on antibiotic resistance patterns to guide antimicrobial therapy.
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Affiliation(s)
- Jennifer Rickard
- 1 University Teaching Hospital of Kigali , Kigali, Rwanda .,2 Department of Surgery, University of Minnesota , Minneapolis, Minnesota.,3 Human Resources for Health , Rwanda
| | - Christian Ngarambe
- 4 Department of Surgery, University Teaching Hospital of Butare , Department of Surgery, Mamba, Butare, Rwanda
| | - Leonard Ndayizeye
- 4 Department of Surgery, University Teaching Hospital of Butare , Department of Surgery, Mamba, Butare, Rwanda
| | - Blair Smart
- 5 Department of Surgery, University of Southern California , Los Angeles, California
| | - Robert Riviello
- 3 Human Resources for Health , Rwanda .,6 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts
| | | | - Rahel G Ghebre
- 3 Human Resources for Health , Rwanda .,8 Department of Obstetrics Gynecology and Women's Health, University of Minnesota , Minneapolis, Minnesota.,9 School of Medicine, Yale University , New Haven, Connecticut
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Antimicrobial Susceptibilities of Aerobic and Facultative Gram-Negative Bacilli from Intra-abdominal Infections in Patients from Seven Regions in China in 2012 and 2013. Antimicrob Agents Chemother 2015; 60:245-51. [PMID: 26482308 DOI: 10.1128/aac.00956-15] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/14/2015] [Indexed: 11/20/2022] Open
Abstract
To evaluate the antimicrobial susceptibility of Gram-negative bacilli that caused hospital-acquired and community-acquired intra-abdominal infections (IAIs) in China between 2012 and 2013, we determined the susceptibilities to 12 antimicrobials and the extended-spectrum β-lactamase (ESBL) statuses of 3,540 IAI isolates from seven geographic areas in China in a central laboratory using CLSI broth microdilution and interpretive standards. Most infections were caused by Escherichia coli (46.3%) and Klebsiella pneumoniae (19.7%). Rates of ESBL-producing E. coli (P = 0.031), K. pneumoniae (P = 0.017), and Proteus mirabilis (P = 0.004) were higher in hospital-acquired IAIs than in community-acquired IAIs. Susceptibilities of enterobacteriaceae to ertapenem, amikacin, piperacillin-tazobactam, and imipenem were 71.3% to 100%, 81.3% to 100%, 64.7% to 100%, and 83.1% to 100%, respectively, but imipenem was ineffective against P. mirabilis (<20%). Although most ESBL-positive hospital-acquired isolates were resistant to third- and fourth-generation cephalosporins, the majority were susceptible to cefoxitin (47.9% to 83.9%). Susceptibilities of ESBL-positive isolates to ampicillin-sulbactam (<10%) were low, whereas susceptibilities to ciprofloxacin (0% to 54.6%) and levofloxacin (0% to 63.6%) varied substantially. The prevalences of cephalosporin-susceptible E. coli and K. pneumoniae were higher in the northeastern and southern regions than in the central and eastern regions, reflecting the ESBL-positive rates in these areas, and were lowest in the Jiangsu-Zhejiang (Jiang-Zhe) area where the rates of carbapenem resistance were also highest. Ertapenem, amikacin, piperacillin-tazobactam, and imipenem are the most efficacious antibiotics for treating IAIs in China, especially those caused by E. coli or K. pneumoniae. Resistance to cephalosporins and carbapenems is more common in the Jiang-Zhe area than in other regions in China.
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