To investigate the clinical and pathogenic characteristics of ventilator-associated pneumonia (VAP) after severe stroke.

Total of 121 mechanically ventilated patients with severe stroke admitted to the intensive care unit of Shanghai Putuo District Central Hospital from January 2018 to January 2023 were divided into VAP group (53 cases) and non-VAP group (68 cases) according to whether complicated with VAP. The clinical characteristics and risk factors of VAP, incidence of VAP at different mechanical ventilation times, and etiological distribution and drug susceptibility characteristics of VAP were analyzed. Measurement data were measured by independent sample t-test or U test and count data were compared by Pearson Chi-square test or Fisher’s exact probability. The risk factors associated with VAP were analyzed by Univariate analysis and multivariate binary Logistic regression analysis.

There were 53 VAP cases in 121 mechanically ventilated patients, and the incidence rate was 43.8% (53/121). The gender, stroke types, the way of endotracheal intubation, rate of gastric tube retention and complications between VAP and non-VAP groups were without significant differences (all P > 0.05), but age, stroke severity, mechanical ventilation duration, length of hospitalization, medical cost, good prognosis and hospital mortality between the two groups were with significant differences (all P < 0.05). Multivariate Logistic regression analysis showed that age (OR = 2.092, 95%CI: 1.507-2.905, P < 0.001) and Glasgow Coma Scale score (OR = 0.248, 95%CI: 0.103-0.599, P = 0.002) were both independent risk factors for VAP. The incidence of VAP was 28.3% (17/60) among patients for 1-7 d, and the incidence of VAP among patients for 8-14 d was 49.0% (24/49), with significant difference (χ² = 4.900, P = 0.027). Compared with patients with mechanical ventilation for 8-14 d (49.0%, 24/49), the incidence of VAP among patients with mechanical ventilation over 14 d was 100% (12/12), with significant difference (P = 0.001). The pathogen distribution of VAP: total of 95 strains of pathogenic bacteria were isolated from the sputum of 53 patients with VAP, including 75.8% (72/95) of Gram-negative bacteria, 16.8% (16/95) of Gram-positive cocci, and 7.4% (7/95) of fungi. Acinetobacter baumannii accounted for the highest proportion of Gram-negative bacteria up to 34.7% (25/72). Gram-positive bacteria were mainly Staphylococcus aureus [56.3 (9/16)]. The drug susceptibility test results showed that the phenomenon of VAP drug-resistance was severe, with Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and Escherichia coli being the four most important Gram-negative resistant bacteria, only sensitive to polymyxin, tigecycline and meropenem. Staphylococcus aureus was the leading Gram-positive resistant bacteria [9 (56.3%)], with extensive resistance to many other antibiotics, except for the low resistance rate to vancomycin [1 (11.1%)], linezolid [1 (11.1%)] and teicoplanin [1 (11.1%)].

Patients with severe stroke had a high incidence of VAP, and age and stroke severity were independent risk factors for VAP, and Acinetobacter baumannii and Staphylococcus aureus were the Gram-negative and positive strains with the highest resistance rate, respectively. VAP has serious adverse effects on stroke prognosis, and aggressive measures are needed to reduce the occurrence of VAP.

To investigate the prevalence of self-administered antibacterial agents use prior to medical consultation among patients in enteric disease clinic, and then take action to improve the education on appropriate antibacterial agents use and promote rational use of antibacterial agents.

Total of 1 349 patients who attended enteric disease clinic of Peking University First Hospital from 1st April to 31st October, 2021 were selected. General data such as demographic characteristics, disease course, clinical manifestations, use of antibacterial agents, and laboratory test results were collected. All patients were grouped according to whether they had used antibacterial agents before consultation to analyze the clinical characteristics of the population using antimicrobials drugs before consultation and assess the rationality of their use of antibacterial agents. The measurement data were analyzed by t test or non-parametric test, and the counting data was analyzed by χ² test.

Total of 1 349 patients were enrolled, including 681 males (50.5%) and 668 females (49.5%). The average age was (44.5 ± 19.09) years old. There were 220 patients (16.31%) who had used antibacterial agents before treatment, and quinolones (110 cases, 50%) was the most, followed by cephalosporins (49 cases, 22.3%) and penicillins (17 cases, 7.7%). Among 220 cases who had used antibacterial agents before consultation, 119 cases (54.1%) were not recommended to use antibacterial agents. Compared with patients who did not use antibacterial agents before treatment, patients who had used antibacterial agents before treatment had higher proportion of college education or above (77.6% vs. 67.0%: χ² = 9.592, P = 0.002), longer course of disease [34 (16, 55) h vs. 24 (10, 50) h: Z =-3.935, P < 0.001], higher maximum body temperature [36.9 (36.5, 38.0) ℃ vs. 36.7 (36.5, 37.2) ℃: Z =-3.563, P < 0.001], and increased frequency of diarrhea [7 (5, 10) vs. 5 (4, 8): Z =-4.464, P < 0.001]. Among patients who had used antibacterial agents before consultation, compared with cases who were not recommended to use antibacterial drugs, cases who recommended to use antibacterial drugs had shorter course of disease [29 (12.5, 44.5) h vs. 44 (18, 74) h: Z =-2.945, P = 0.003], higher maximum body temperature [37.4 (36.7, 38.5) ℃ vs. 36.7 (36.4, 37.0) ℃: Z =-4.572, P < 0.001], elevated fecal white blood cell count [3 (0, 15)/HP vs. 0 (0, 0)/HP: Z =-6.658, P < 0.001], higher percentage of vomiting (28.7% vs. 16.8%: χ² = 4.473, P = 0.034) and higher percentage of fever (55.4% vs. 22.7%: χ² = 24.951, P < 0.001). Among patients who did not use antibacterial agents before consultation, compared with cases who were not recommended to use antibacterial drugs, cases who were recommended to use antibacterial drugs had shorter course of disease [19 (8, 37) h vs. 26 (11, 56) h: Z =-4.331, P < 0.001], higher maximum body temperature [36.9 (36.5, 37.9) ℃ vs. 36.6 (36.5, 37.0) ℃: Z =-6.723, P < 0.001], increased incidence of diarrhea [6 (4, 10) vs. 5 (4, 8): Z =-3.512, P = 0.001], elevated fecal white blood cell count [1 (0, 15)/HP vs. 0 (0, 0)/HP: Z =-12 .237, P < 0.001], higher percentage of abdominal pain (70.4% vs. 58.3%: χ² = 14.601, P < 0.001), nausea (48.4% vs. 39.3%: χ² = 7.871, P = 0.005), fever (37.7% vs. 16.5%: χ² = 58.642, P < 0.001) and tenesmus (25.8% vs. 19.9%: χ² = 4.685, P = 0.030). Compared with cases with course from onset to consultation > 24 hours, patients with course from onset to consultation < 24 hours had higher maximum body temperature [36.8 (36.5, 37.5) ℃ vs. 36.6 (36.4, 37.0) ℃: Z =-4.756, P < 0.001], higher proportion of abdominal pain (66.2% vs. 58.2%: χ² = 7.120, P = 0.008), nausea (50.8% vs. 33.9%: χ² = 31.025, P < 0.001), vomiting (33.11% vs. 13.9%: χ² = 54.867, P < 0.001) and fever (28.6% vs. 18.2%: χ² = 16.122, P < 0.001). Compared with cases with course from onset to consultation > 48 hours, patient with course from onset to consultation < 48 hours had higher maximum body temperature [36.8 (36.5, 37.4) ℃ vs. 36.6 (36.4, 36.9) ℃: Z =-4.847, P < 0.001], with higher proportion of abdominal pain (64.4% vs. 56.4%: χ² = 5.660, P = 0.017), nausea (46.2% vs. 31.8%: χ² = 17.820, P < 0.001), vomiting (28.3% vs. 10.4%: χ² = 37.737, P < 0.001), and fever (27.5% vs. 12.1%: χ² = 28.019, P < 0.001).

At present, pre-hospital antimicrobial drug abuse is still a serious phenomenon among patients in enteric disease clinic, and it is necessary to strengthen the management of antibiotics. The highly educated, middle-aged and young people can be taken as the key education targets, emphasizing that the frequency of diarrhea and high body temperature are not indications of antibacterial agents, and the long course of disease cannot be used as the standard to guide the application of antibiotics.

To investigate the pathogen distribution of metagenomic next-generation sequencing (mNGS) for bronchoalveolar lavage fluid (BALF) in children with severe pneumonia and its application value in children with severe pneumonia.

Blood samples and respiratory samples of children diagnosed with severe pneumonia in the respiratory department of Xi’an Children’s Hospital from May 2019 to June 2022 were collected, the pathogens were simultaneously tested by traditional microbiological assays and mNGS, and the pathogen detection rates and the coincidence rate with the clinical diagnosis of the two methods were compared. The pathogenic distribution of mNGS in BALF of children with severe pneumonia was analyzed. Enumeration data (gender, age, clinical symptoms, imaging, clinical outcome; positive rate of pathogen detection, clinical coincidence rate and true positive rate) were represented by rates or composition ratios, and were conducted by Pearson Chi-square test.

Total of 79 children with severe pneumonia were enrolled. Among them, 52 were male and 27 were female, aged from 1 month to 14 years and 4 months; the positive rate of pathogens detected by mNGS was 84.8% (67/79), 73.4% (58/79) were consistent with clinical diagnosis, the true positive rate was 86.5% (58/67). While, 32 cases (40.5%) were positive by traditional detection assays, 26.6% (21/79) cases were consistent with clinical diagnosis, and the true positive rate was 65.6% (21/32). These rates of mNGS were significantly higher than those of traditional detection, with significance differences (χ² = 33.14, P < 0.001; χ² = 34.66, P < 0.001; χ² = 5.89, P = 0.015). Bacteria were the most common pathogens of severe pneumonia in all age groups (< 6 months, 6 months to 2 years, 2 to 5 years and > 5 years), with significance differences (χ² = 22.05, 42.71, 37.79, 22.77; all P < 0.001). Streptococcus pneumoniae (SP) was the most common pathogen, and mycoplasma pneumoniae (MP) was the second common pathogen in the patients over 5 years old. Spring and winter were the peak seasons for severe pneumonia in children, with significance differences (χ² = 12.65, 27.24; both P < 0.001).

Compared with traditional detection assays, mNGS detection of pathogenic microorganisms in BALF in children with severe pneumonia can significantly improve the pathogen detection rate and clinical judgment coincidence rate. SP was the most common pathogen of severe pneumonia in children of all ages, and MP was the main pathogen of severe pneumonia in children over 5 years old. Severe pneumonia in children was more common in spring and winter.

To explore the clinical efficacy of one-stage posterior computer navigation-assisted pedicle screw placement, lesion removal, intervertebral bone graft fusion and internal fixation in the treatment of thoracic brucellosis spondylitis.

From September 2015 to October 2019, 19 patients with thoracic brucellosis spondylitis were retrospectively analyzed. There were 12 males and 7 females, aged from 28-66 years (average, 46.8 ± 11.0 years old). All patients had chest and back pain, 13 (68.4%) patients had different degrees of sensory and motor dysfunction, and all the patients underwent one-stage posterior computer navigation-assisted pedicle screw placement, lesion removal, intervertebral bone graft fusion and internal fixation. The Visual Analogue Scales (VAS), American Spinal Injury Association (ASIA), Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) are used for clinical efficacy evaluation.

Postoperatively, 112 pedicle screws were located in Grade I, and the accuracy rate of screw placement was 93.3% (112/120). The follow-up was 12-36 months, with an average (20.9 ± 6.6) months. The chest and back pain of all patients was significantly reduced after surgery, and the sensory motor function was significantly improved. At 2 weeks after operation, 3 months after operation and the last follow-up, the VAS score was statistically different from that before operation (all P < 0.001), but there was no statistical difference between the last follow-up and 3 months after operation (Z =-1.414, P = 0.157). At 2 weeks after operation, ESR and CRP were statistically different from those before operation (all P < 0.001). At 3 months after operation, ESR and CRP basically dropped to normal. At 3 months after operation and the last follow-up, ESR and CRP were statistically different from those before and 2 weeks after operation (all P < 0.001), but there was no statistical difference between the last follow-up and 3 months after operation (t = 2.464, P = 0.053; t = 1.711, P = 0.102). The ASIA classification of 13 patients with spinal cord or nerve compression symptoms before the operation was 1 case of grade B, 2 cases of grade C and 10 cases of grade D. At the last follow-up, there were 2 cases of grade D and 11 cases of grade E, with statistical difference (χ² = 11.621, P = 0.009). In addition, all patients had bone graft fusion at the last follow-up without complications such as recurrence, loosening of internal fixation and displacement.

The treatment of thoracic brucellosis spondylitis with the aid of computer navigation has the characteristics of high accuracy of pedicle screw placement, and can effectively remove the lesion tissue, eliminate chest and back pain, and restore sensory and motor function. The clinical effect is satisfactory.

To analyze drug resistance of carbapenem resistant Pseudomonas aeruginosa (CRPA), and to investigate the in vitro susceptibility test result of colistin (COL) combined with meropenem (MEM), ceftazidime (CAZ), piperacillin/tazobactam (TZP), ciprofloxacin (CIP) and amikacin (AK) combined with TZP, CIP and TZP combined with CIP to CRPA for screen the effective anti-infective therapy.

Total of 22 strains of CRPA were isolated from clinic specimens from Qingdao Eighth People’s Hospital from January 2022 to December 2022. The minimal inhibitory concentration (MIC) of antimicrobial agents against CRPA strains was determined by micro broth dilution method. Combined antimicrobial susceptibility test was performed by the chessboard dilution method. Fractional inhibitory concentration (FIC) index was calculated to determine the combined effect.

The resistance rates of CRPA to piperacillin (PRL), cefoperazone/sulbactam (SCF), Aztreonam (ATM), imipenem (IPM) and MEM were higher than 90%. The resistance rates to cefepime (FEP), TZP, levofloxacin (LEV), CAZ, CIP, gentamicin (CN), tobramycin (TOB) and AK were 81.8% (18/22), 77.3% (17/22), 77.3% (17/22), 72.7% (16/22), 68.2% (15/22), 63.6% (14/22), 63.6% (14/22) and 54.5% (12/22), respectively. The resistance rates to CZA and COL were 9.1% (2/22) and 0 (0/22), respectively. The results of antimicrobial synergy study showed that the synergistic rates of COL and MEM were 59.1% (13/22), and the sum of synergistic rates and additive rates were 100% (22/22). The synergistic rates of COL + CAZ, COL + TZP, COL + CIP, AK + CIP, TZP + CIP were 45.4% (10/22), 54.5% (12/22), 31.8% (7/22), 22.7% (5/22), 31.8% (7/22) and 9.1% (2/22), and the sum of synergistic rates and additive rates were 81.8% (18/22), 90.9% (20/22), 77.3% (17/22), 77.3% (17/22), 68.2% (15/22) and 59.1% (13/22), respectively. No antagonism effect was observed for all combinations.

CZA alone is effective for CRPA sensitive strains. Among all the combinations, COL + MEM had the highest synergy rate and addition rate, TZP and CIP has the lowest synergy rate and addition rate, which could provide reference for clinical experience medication.

To analyze a case with tuberculous meningitis complicated with paradoxical reaction, and to raise the attention to tuberculous meningitis complicated with paradoxical reaction.

The clinical data, diagnosis and treatment process and prognosis of a patient with tuberculous meningitis complicated with paradoxical reaction admitted to Peking Union Medical College Hospital, Chinese Academy of Medical Sciences on September 8th 2020 were analyzed, retrospectively.

The patient presented clinically with headache and fever, the cerebrospinal fluid examination showed that the intracranial pressure was significantly increased, the white blood cells and protein level were high, and the chlorine level was low. Mycobacterium tuberculosis infection of T cells spot test were positive both in peripheral blood and cerebrospinal fluid, brain Magnetic Resonance Imaging (MRI) showed multiple abnormal signals, while the rest of the etiological examination was negative. The patient was considered tuberculous meningitis and started diagnostic anti-tuberculosis treatment. The clinical symptoms and cerebrospinal fluid tests improved for a while, but the condition deteriorated again after the reduction of glucocorticoids. The patient was considered paradoxical reaction. After increased doses of glucocorticoid, the patient improved rapidly. MRI at 1 year was essentially unremarkable.

Tuberculous meningitis complicated with paradoxical reaction is rare, which is easy to be misdiagnosed and delayed to receive treatment. Therefore, clinicians are reminded to be alert to tuberculous meningitis complicated by paradoxical reaction for patient with aggravation of the disease after anti-tuberculosis treatment, high-dose glucocorticoids is the preferred treatment.

To investigate the clinical characteristics, diagnosis and treatment of diabetic ketoacidosis (DKA) induced by skin soft tissue infection caused by Aspergillus fumigatus.

The clinical features, risk factors, diagnosis and treatment of a patient with DKA and Aspergillus fumigatus infection of skin and soft tissue as the first manifestation were analyzed in January 2022 in Traditional Chinese Hospital of Lu’an.

The patient, a 29-year-old male without history of diabetes, presented with a suppurative infection of the soft tissues of the back as the first manifestation. The patient was diagnosed as DKA by relevant examination on admission and received initial anti-infection treatment with piperacillin and tazobactam (4.5 g/time, intravenous infusion, once/8 h, course of treatment: 21 days). The patient’s purulent secretions were cultured for 3 days, suggesting Aspergillus fumigatus and was given antifungal therapy with voriconazole (200 mg/time, intravenous infusion, once/12 h, doubled on the first day, course of treatment: 19 days). After orthopedic consultation, the focus removal was performed. The histopathology showed that there were a lot of granulation tissue with necrosis. During the operation, the purulent tissue was cultured for 3 days and reported positive (Aspergillus fumigatus). After anti-infective treatment, the patient’s purulent lesion gradually shrank and was discharged successfully. During the operation, the purulent tissue was cultured for 3 days, which suggested Aspergillus fumigatus. After anti-infection treatment with piperacillin and tazobactam (4.5 g/time, intravenous infusion, once/8 h, course of treatment: 21 days) + voriconazole (200 mg/ time, intravenous infusion, once/12 h, course of treatment: 19 days), the patient was discharged successfully.

The suppurative infection of deep soft tissue caused by Aspergillus fumigatus is rarely reported, the clinical manifestations are not specific, and DKA is rare. For patients with underlying immune dysfunction complicated with soft tissue infection, the possibility of fungal infection should be considered combined with molecular biology and microbial culture, and early diagnosis and treatment should be considered to improve the prognosis.

To investigate the clinical characteristics and diagnostic points of urinary tract tuberculosis.

The clinical data of a patient with urinary tract tuberculosis who suffered from weight loss, recurrent fever, fatigue and headache, admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine on June 17th, 2022 were analyzed and relevant literatures were reviewed.

The patient was a 58-years-old female who has lost 7.5 kg weight in the past six months. The case developed a fever longer than a week ago and a low fever in the afternoon, with a maximum body temperature of 37.7 ℃, and complicated with fatigue and headache. The chest CT scan showed proliferative lesions and lymph nodes in both upper lobes of the lungs, and fibrous lesions in the middle lobe of the right lung, without any signs of Mycobacterium tuberculosis infection. Color doppler ultrasound showed no obvious enlarged lymph nodes in both necks, thickening of the intima media in both carotid arteries, no obvious abnormalities in both vertebral arteries, cystic hyperplasia of both breasts, no obvious enlarged lymph nodes in both armpits. After cholecystectomy, no obvious dilation of the intrahepatic and extrahepatic bile ducts was observed, and no obvious abnormalities were found in liver, pancreas and spleen. No obvious abnormalities were found in both kidneys, ureters and bladder. Urinary routine: negative occult blood in urine, urinary red blood cells was 5 cells/μl. The Mycobacterium tuberculosis infection T cell spot test (T-SPOT.TB) showed 5 spots on MTB antigen (ESAT-6) and 1 spot on MTB antigen (CFP-10), the result was negative, while the purified protein derivative test (PPD) showed a positive result for a wind mass diameter of 35 mm × 18 mm. The result of random urine test for acid fast bacteria was negative, and 12 hours of urine test for acid fast bacteria was positive for 2 consecutive times, and finally the patient was discharged from the hospital with urinary tract tuberculosis infection as the main diagnosis and transferred to the designated tuberculosis hospital for further treatment.

Early diagnosis of urinary tract tuberculosis is difficult and a comprehensive analysis of clinical manifestations and various examination results is required.