The role of Type VI Secretion System in resistance and pathogenicity of Acinetobacter baumannii

The role of Type VI Secretion System in resistance and pathogenicity of Acinetobacter baumannii | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The role of Type VI Secretion System in resistance and pathogenicity of Acinetobacter baumannii Jun Li, Mengli Tang, Zhaojun Liu, Haolan Wang, Yubing Xia, Yongmei Hu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9192368/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract The Type VI secretion system (T6SS) is a multi-component transmembrane apparatus that is crucial for substance acquisition and pathogenicity of bacteria. In this study we investigated Acinetobacter baumannii , a causative agent of bacteremia, to explore the mechanisms of T6SS in drug resistance and pathogenicity by contrasting virulence, drug sensitivity, conjugation, transformation, competition, and cell adhesion capacities. A total of 136 non-repetitive A. baumannii strains were collected, and 80.1% of patients received treatment in intensive care unit. Forty (29.4%) were classified as hypervirulent A. baumannii (hvAB), which exhibited a higher prevalence of the virulence gene abaI , a reduced capacity for biofilm formation, and a lower prevalence of the outer membrane protein gene carO . T6SS-positive strains exhibited enhanced antimicrobial resistance, elevated frequencies of resistance genes ( bla OXA−23−like , bla TEM , adeB , adeR , adeS ) and the virulence gene csuE . Differences were observed between strains with T6SS deletion and those with an intact T6SS concerning the HigAB toxin-antitoxin system and the RSF1010-like IncQ plasmid. T6SS may down-regulate the expression of effector genes due to the insertion sequence IS Aba13 . The critical role of the T6SS in the drug resistance and pathogenicity of A. baumannii necessitates strengthened surveillance and the prompt implementation of effective measures. Biological sciences/Microbiology Biological sciences/Molecular biology Acinetobacter baumannii Type VI secretion system Resistance Pathogenicity Insertion sequence Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Acinetobacter baumannii , recognized as a significant pathogen associated with nosocomial infections, has exhibited a growing resistance to antibiotics in recent years, with the emergence of strains resistant to polymyxins [ 1 , 2 ]. Due to its critical issue of drug resistance, it has been classified as a critical priority pathogen in the recently released list of bacterial priority pathogens by World Health Organization (WHO) ( https://www.WHO.int/publications/i/item/9789240093461 ). Recent studies have identified a virulence-enhancing strain of A. baumannii , referred to as hypervirulent A. baumannii (hvAB). This strain has been shown to have a higher propensity to cause infections in immunocompromised patients, resulting in an increased mortality rate associated with bloodstream infections [ 3 , 4 ]. The Type VI secretion system (T6SS) is a multi-component transmembrane apparatus that relies on cell-to-cell contact and is prevalent among various gram-negative bacteria, including Vibrio cholerae , Pseudomonas aeruginosa , Escherichia coli , A. baumannii , and Klebsiella pneumoniae . The T6SS gene cluster is comprised of 13 conserved core genes ( tss genes), T6SS-related genes ( tag genes) and T6SS effector genes ( tse genes) [ 5 ]. Bacteria utilize T6SS to secrete a variety of effector proteins, fulfilling various biological functions. These functions include roles in pathogenicity, the recognition of foreign species, the uptake of metal ions, the formation of biofilms, and responses to environmental stressors [ 6 – 9 ]. Recent research has indicated a potential correlation between T6SS and antimicrobial resistance and virulence of bacteria [ 10 , 11 ]. An hcp -deletion mutant demonstrated a significantly diminished capacity to acquire resistance plasmids from E. coli JM109P [ 12 ], and the vgrG -deletion variant of A. baumannii exhibited enhanced resistance to ampicillin-sulbactam (SAM), a diminished growth rate, impaired adhesion to eukaryotic cells, and reduced virulence in murine infection models [ 13 ]. Nevertheless, the role of T6SS in mediating resistance and pathogenicity in A. baumannii is poorly understood. In this study, we collected clinical isolates of A. baumannii from blood samples and identified hvAB. We compared drug resistance, virulence, plasmid conjugation, transformation, bacterial competition, and cell adhesion between T6SS-positive strains (AB T6SS+ ) and T6SS-negative strains (AB T6SS− ) in order to clarify the role of T6SS in the resistance and pathogenicity of A. baumannii . Methods Bacterial strains and clinical data Non-repetitive A. baumannii strains were collected from blood samples at Xiangya Hospital of Central South University between January 2017 and October 2020. The strains were re-identified using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS; Bruker Daltonics GmbH, Germany) and 16S rRNA sequencing, using E. coli ATCC 25922 (National Center for Clinical Laboratories, China) as the quality control strain. Clinical data were collected, including sex, age, department, pre-existing medical conditions, complications, antibiotic administration, invasive procedures, etc. Antimicrobial susceptibility testing Antimicrobial susceptibility testing was conducted utilizing the micro-broth dilution method (Wenzhou Kont Biotechnology Company, China). The determination of susceptibility results was guided by the Clinical and Laboratory Standards Institute (CLSI) 2022 criteria [ 14 ]. TGC was determined according to the Food and Drug Administration (FDA) breakpoint. Identification of resistance genes, virulence genes, and core genes of T6SS Genes associated with resistance, virulence, and the core components T6SS ( hcp , tssM ) were identified using polymerase chain reaction (PCR). The specific primers along with the PCR conditions were established based on prior research [ 10 , 15 – 19 ]. A detailed compilation of genes and primers is available in Supplementary Material S1 Table. Biofilm formation assay Biofilm formation was assessed by crystal violet staining method [ 20 ]. The strains were prepared in a suspension of 1.0×10 8 CFU/mL, subsequently diluted and cultured in a 96-well plate (3 parallel wells for each strain) at 37°C for 24 h, then stained with 1% crystal violet, and decolorized with 95% ethanol. The optical density (OD) was measured at a wavelength of 570 nm (OD 570 ). Galleria mellonella infection model The assay was modified based on a previous study [ 21 ]. G. mellonella larvae (Tianjin Huiyude Biotechnology Company, China) were randomly selected and allocated into groups of ten. The strains were prepared into 1.0×10 7 CFU/mL suspension with PBS. Each larva received an injection of 10 µL of the bacterial suspension and incubated at 37°C in the dark for 5 days. Mortality was monitored and recorded at 24-hour intervals. The strains AB5075 and A. baumannii ATCC 19606 served as controls for high and low virulence, respectively. Whole-genome sequencing (WGS) and data analysis Genomic DNA was extracted using the TIANamp Bacteria DNA Kit (TIANGEN Biotech, China). Sequencing was performed on the Novaseq 6000 and PromethION platforms. Multilocus sequence typing (MLST) was analyzed via PubMLST. Core genomes single-nucleotide polymorphisms (cg-SNPs) were called with Snippy and used for phylogenetic reconstruction. Resistance and virulence genes were identified using Comprehensive Antibiotic Resistance Database (CARD) and Virulence Factor Database (VFDB), respectively. Phylogenetic trees were visualized with ChiPlot. Genome annotation was performed with RAST 2.0. Plasmid types and insertion sequences were predicted using Plasmid MLST and IS Finder, respectively. Comparative genomics and T6SS cluster variations were analyzed with BRIG [ 22 ] and Easyfig [ 23 ]. The data supporting this study's findings are openly available in the NCBI BioProject repository under BioProject accession number PRJNA1206144. Natural transformation, bacterial competence and competitive transformation The micro-broth dilution method was used to identify kanamycin-sensitive strains for use in natural transformation, bacterial competence, and competitive transformation assays. Assay was modified based on previous studies [ 12 , 24 ]. Natural transformation: Strains were prepared into 1.5×10 8 CFU/mL suspension. A volume of 10 µL of the bacterial suspension was combined with 10 µL of the plasmid pBAV1K-T5-sfGFP (Abiowell Biotechnology Co., Ltd., Changsha, China), which contains a kanamycin resistance gene. This mixture was inoculated onto motility medium (MM) plates and incubated at 37°C overnight. Colonies were counted and the pBAV1K-T5-sfGFP plasmid was confirmed through PCR. Bacterial competence: The pBAV1K-T5-sfGFP plasmid carrying a kanamycin resistance gene was transformed into E. coli strain TG1, generating the strain named TG1P. A. baumannii strains and TG1P were prepared into 1.5×10 8 CFU/mL suspension. 100 µL of TG1P was combined with 10 µL of A. baumannii , and a 10 µL aliquot of this mixture was applied to an LB agar plate then incubated at 37℃ for 24 h. LB agar supplemented with kanamycin was used to select for viable E. coli . Competitive transformation: A. baumannii strains and TG1P were prepared into 1.5×10 8 CFU/mL suspension. A 20 µL mixture was prepared at an A. baumannii to E. coli (AB:EC) ratio of 1:9, and 7 µL of this mixture was inoculated onto MM plates then incubated at 37°C overnight. LB agar supplemented with kanamycin and ampicillin was used to select for A. baumannii that acquired the pBAV1K-T5-sfGFP plasmid from TG1P. Colonies were enumerated to determine the conversion rates. Cell adhesion Human normal lung epithelial cells BEAS-2B (from the research group of Professor Pinhua Pan, Xiangya Hospital, Central South University) were used as infected cells. A. baumannii was introduced at a multiplicity of infection (MOI) of 50. After BEAS-2B cells infected with A. baumannii for durations of 1, 2, and 3 h, unattached bacteria were removed, and cells were lysed, the number of bacteria adhering to the BEAS-2B cells were counted. Adhesion rate = (number of counted colonies × dilution factor) / (number of bacteria inoculated in the wells) × 100%. Results Clinical features of patients with bloodstream infections caused by A. baumannii A total of 136 strains of A. baumannii were isolated from patients diagnosed with bloodstream infections. The predominant demographic consisted of male patients, accounting for 77.2% (105/136), with a mean age of 49.5 years (33.0–60.0). The majority of these patients were admitted to the departments of critical care medicine (49.3%, 67/136) and burn surgery (13.2%, 18/136). The primary complications observed included pulmonary infections (64.0%, 87/136), hepatobiliary diseases (38.2%, 52/136), urinary system diseases (35.3%, 48/136), septic shock (33.1%, 45/136), multiple organ dysfunction syndrome (MODS, 27.9%, 38/136), hypertension (21.3%, 29/136), and severe pneumonia (20.6%, 28/136). Prior to the identification of A. baumannii bloodstream infections, 128 patients (94.1%) had received antibiotic treatment, 127 patients (93.4%) had indwelling catheters or had undergone invasive procedures, and 101 patients (74.3%) had been treated in the intensive care unit (ICU). Following the onset of A. baumannii bloodstream infections, 109 patients (80.1%) received ICU treatment. Among the cohort, 45 patients (33.1%) did not recover, 43 patients (31.6%) died, and 35 patients (25.7%) died within 30 days of the A. baumannii bloodstream infection diagnosis. Notable differences were observed in the use of imipenem (IPM) prior to infection (44.2% in deceased patients versus 23.7% in survivors, P = 0.015268), the administration of cefoperazone/sulbactam (SCF) within 72 h post-infection (18.6% in deceased patients compared to 46.2% in survivors, P = 0.001968), and the incidence of MODS (39.5% in deceased patients vs. 22.6% in survivors, P = 0.040473) (Table 1 ). Table 1 Comparison of clinical characteristics between deceased and surviving patients Clinical characteristics Death ( n = 43) Survival ( n = 93) P N % N % Age 50.0 (35 ~ 61) - 49.0 (31 ~ 60) - 0.575826 Sex Male 35 81.4 70 75.3 0.428404 Female 8 18.6 23 24.7 Department Critical care medicine 22 51.2 45 48.4 0.763368 Burn surgery 6 14.0 12 12.9 0.866536 Respiratory internal medicine ICU 3 7.0 5 5.4 1.000000 Complication Lung infections 27 62.8 60 64.5 0.845481 Septic shock 16 37.2 29 31.2 0.487357 MODS 17 39.5 21 22.6 0.040473* Hypertension 10 23.3 19 20.4 0.708334 Severe pneumonia 9 20.9 19 20.4 0.946525 Tumor 7 16.3 17 18.3 0.775984 Diabetes 7 16.3 10 10.8 0.364870 ICU treatment during hospitalization 39 90.7 77 82.8 0.226331 Total number of days in hospital 22.0 (11.0 ~ 40.0) - 25.0 (13.0 ~ 51.5) - 0.289019 ICU treatment before infection 9.0 (2.0 ~ 11.0) - 7.0 (0.0 ~ 12.5) - 0.268897 Use of antibiotics before infection Meropenem 13 30.2 43 46.2 0.077844 Imipenem 19 44.2 22 23.7 0.015268* Cefoperazone/sulbactam 14 32.6 27 29.0 0.676943 Tigecycline 7 16.3 15 16.1 0.982373 Invasive procedures before infection Central venous catheter 21 48.8 42 45.2 0.689347 Catheter 27 62.8 64 68.8 0.487357 Invasive mechanical ventilation 21 48.8 44 47.3 0.868479 Arterial catheterization 28 65.1 54 58.1 0.434498 PICC 5 11.6 21 22.6 0.130948 Antibiotics used within 72 h of infection Cefoperazone/sulbactam 8 18.6 43 46.2 0.001968* Meropenem 14 32.6 18 19.4 0.091438 Tigecycline 18 41.9 37 39.8 0.818618 Imipenem 13 30.2 25 26.9 0.685520 WBC count 9.5 (4.4 ~ 13.9) - 10.1 (6.2 ~ 15.6) - 0.317672 NEUT% 88.3 (72.2 ~ 93.5) - 88.1 (77.5 ~ 94.0) - 0.644793 Note: * P < 0.05 is considered statistically significant. Characteristics of hvAB strains and clinical features of patients infected with hvAB The detection rates for the genes ompA , bap , abaI , csuE , and bfmS are shown in Fig. 1 a. Based on the criteria from the literature, strains that possessed multiple common virulence-associated genes and exhibited 3-day mortality rates of 80% or greater in infected G. mellonella , and whose patients either failed to recover or died during hospitalization, were classified as hvAB (Fig. 1 b) [ 4 ]. Consequently, a total of 40 (29.4%) strains were identified as hvAB. Thirty-eight strains (95%) of hvAB were identified as carbapenem-resistant hypervirulent A. baumannii (CR-hvAB). The comparative characteristics of hvAB and non-hvAB strains are presented in Table 2 . In contrast to non-hvAB strains, hvAB exhibited a significantly higher prevalence of the virulence gene abaI (92.5% vs. 76.0%, P = 0.026147) and a lower prevalence of the outer membrane protein-associated resistance gene carO (77.5% vs. 90.6%, P = 0.039585). However, the capacity for biofilm formation was diminished in hvAB strains (55.0% vs. 34.4%, P = 0.025543, as illustrated by the OD value in Fig. 1 c). Table 2 Comparative characteristics of hvAB and non-hvAB strains Characteristics hvAB( n = 40) non-hvAB( n = 96) P N % N % Resistance Imipenem 38 95.0 85 88.5 0.396920 Meropenem 38 95.0 85 88.5 0.396920 Cefepime 38 95.0 84 87.5 0.316438 Ceftazidime 39 97.5 85 88.5 0.178136 Ciprofloxacin 38 95.0 85 88.5 0.396920 Levofloxacin 24 60.0 53 55.2 0.532438 Gentamicin 36 90.0 79 82.3 0.256987 Amikacin 36 90.0 76 79.2 0.131038 Tobramycin 34 85.0 80 83.3 0.809941 Piperacillin/tazobactam 38 95.0 85 88.5 0.396920 Cefoperazone/sulbactam 31 77.5 63 65.6 0.172009 Tigecycline 0 0 3 3.1 0.555165 No/weak film formation 22 55.0 33 34.4 0.025543* Virulence-related genes ompA 40 100.0 96 100.0 - bfmS 36 90.0 94 97.9 0.111776 csuE 35 87.5 93 96.9 0.085931 abaI 37 92.5 73 76.0 0.026147* bap 29 72.5 77 80.2 0.323236 Resistance genes bla OXA−23−like 35 87.5 82 85.4 0.749485 bla TEM 38 95.0 79 82.3 0.051434 bla NDM−1 0 0 3 3.1 0.555165 carO 31 77.5 87 90.6 0.039585* adeB 40 100.0 94 97.9 1.000000 adeE 0 0 0 0 - adeG 39 97.5 93 96.9 1.000000 adeJ 22 55.0 46 47.9 0.451587 adeR 39 97.5 91 94.8 0.808329 adeS 40 100.0 91 94.8 0.321194 abeM 40 100.0 96 100.0 - Note: * P < 0.05 is considered statistically significant. As shown in Table 3 , patients infected with hvAB exhibited a significantly higher incidence of severe pneumonia, with rates of 35.0% compared to 14.6% in those with non-hvAB ( P = 0.007295). Conversely, patients with non-hvAB infection demonstrated a greater prevalence of concurrent tumors, with 21.9% compared to 7.5% in the hvAB-infected group ( P = 0.045104). Table 3 Comparison of clinical characteristics in patients with hvAB versus non-hvAB infections Clinical characteristics hvAB( n = 40) Non-hvAB ( n = 96) P N % N % Age 41.0 (21.5 ~ 55.0) 50.0 (37.0 ~ 61.0) 0.055373 Sex Male 31 77.5 74 77.1 0.957909 Female 9 22.5 22 22.9 Department Critical care medicine 21 52.5 46 47.9 0.626159 Burn surgery 5 12.5 13 13.5 0.870253 Respiratory internal medicine ICU 4 10.0 4 4.2 0.358911 Complication Lung infections 28 70.0 59 61.5 0.344450 Septic shock 16 40.0 29 30.2 0.268826 MODS 12 30.0 26 27.1 0.729797 Severe pneumonia 14 35.0 14 14.6 0.007295* Tumor 3 7.5 21 21.9 0.045104* Hypertension 8 20.0 21 21.9 0.807815 Diabetes 4 10.0 13 13.5 0.569327 Total days in hospital 20.5 (14.8 ~ 37.3) 25.0 (13.0 ~ 44.0) 0.730885 ICU treatment before infection 29 72.5 72 75.0 0.761231 Use of antibiotics before infection Meropenem 16 40.0 40 41.7 0.857194 Imipenem 16 40.0 25 26.0 0.106035 Cefoperazone/sulbactam 13 32.5 28 29.2 0.699515 Tigecycline 8 20.0 14 14.6 0.434430 Invasive procedures before infection Central venous catheter 21 52.5 43 44.8 0.411866 Catheter 25 62.5 66 68.8 0.480306 Invasive mechanical ventilation 20 50.0 45 46.9 0.739565 Arterial catheterization 25 62.5 57 59.4 0.734326 PICC 6 15.0 20 20.8 0.430545 No improvement after 72 h 29 72.5 70 72.9 0.960320 Death during hospitalization 16 40.0 27 28.1 0.174768 Note: * P < 0.05 is considered statistically significant. Abbreviations: ICU, intensive care unit; MODS, multiple organ dysfunction syndrome; PICC, peripherally inserted central venous catheter. Genetic and phylogenetic analysis of CR-hvAB Figure 2 illustrates the phylogenetic tree, ST types, T6SS classifications, virulence factors, and resistance genes of the CR-hvAB strains. The predominant sequence types identified were ST457 (12/38, 31.6%) and ST195 (8/38, 21.1%). A variety of resistance genes were identified. All CR-hvAB isolates were found to possess virulence-associated genes including ompA , abaR , bap , bfmR , and bfmS . The CR-hvAB isolates obtained from patients with A. baumannii bloodstream infections (AB-BSI) were categorized into three distinct clades, with strains of the same sequence type exhibiting close genetic relationships. Variations in cg-SNPs between the two strains of CR-hvAB were found to range from 0 to 131. Notably, the number of cg-SNP variations among six designated groups was ≤ 8. These strains are considered closely related in a clinical context and may originate from the same transmission chain [ 25 ]. The association between T6SS and the resistance and virulence Among 136 A. baumannii strains, 116 (85.3%) were found to possess hcp and tssM genes. Compared with AB T6SS− , AB T6SS+ exhibited significantly higher resistance rates to the majority of commonly used antibiotics ( P < 0.05). The prevalence of gene bla OXA−23−like , gene bla TEM , the efflux pump genes adeB , adeR , adeS , and the virulence-associated gene csuE were also significantly greater in AB T6SS+ ( P < 0.05). (Table 4 ). Table 4 Comparison of characteristics of AB T6SS+ and AB T6SS− Characteristics AB T6SS+ ( n = 116) AB T6SS− ( n = 20) P N % N % Resistance Imipenem 111 95.7 12 60.0 0.000004* Meropenem 111 95.7 12 60.0 0.000004* Cefepime 110 94.8 12 60.0 0.000015* Ceftazidime 112 96.6 12 60.0 0.000001* Ciprofloxacin 111 95.7 12 60.0 0.000004* Levofloxacin 69 59.5 8 40.0 0.104450 Gentamicin 104 89.7 11 55.0 0.000288* Amikacin 102 87.9 10 50.0 0.000149* Tobramycin 103 88.8 11 55.0 0.000537* Piperacillin/tazobactam 111 95.7 12 60.0 0.000004* Cefoperazone/sulbactam 84 72.4 10 50.0 0.045098* No/weak film formation 51 44.0 8 40.0 0.741039 hypervirulence 35 30.2 5 25.0 0.639171 Virulence-related genes ompA 116 100.0 20 100.0 - bfmS 110 94.8 20 100.0 0.591808 csuE 114 98.3 14 70.0 0.000009* abaI 97 83.6 13 65.0 0.099363 bap 94 81.0 12 60.0 0.071346 Resistance genes bla OXA−23−like 105 90.5 12 60.0 0.001014* bla TEM 106 91.4 11 55.0 0.000068* bla NDM−1 0 0.0 2 10.0 0.020697* carO 98 84.5 20 100.0 0.125025 adeB 116 100.0 18 90.0 0.020697* adeE 0 0.0 0 0.0 - adeG 114 98.3 18 90.0 0.103007 adeJ 57 49.1 11 55.0 0.628220 adeR 114 98.3 16 80.0 0.004346* adeS 115 99.1 16 80.0 0.001605* abeM 116 100.0 20 100.0 - Note: * P < 0.05 is considered statistically significant. Table 5 Genomic characteristics of strains based on long-read sequencing Strain T6SS ST type Genome size (bp) G + C (%) CDS (n) Plasmid number (n) MEGs (n) AB26 Partially absent 457 3,972,415 38.97 3,798 2 45 AB51 Complete 457 3,950,629 39.03 3,760 1 58 AB41 Completely absent 195 3,996,747 38.98 3,840 2 39 AB78 Complete 195 4,059,951 39.11 3,858 2 48 Abbreviations: G + C, G and C bases; CDS, coding sequence; MEGs, mobile genetic elements. A total of 57 strains, comprising 38 CR-hvAB strains and 19 non-hvAB strains with various ST types, were selected for sequencing the T6SS structure. T6SS of A. baumannii exhibited a relatively conserved nature. The majority of the T6SS structures were found to be complete, designated as T6SS-1A (Fig. 3 a, T6SS-complete), which constituted 75.4% (43/57) of the strains. Strains exhibiting partial deletion (Fig. 3 a, T6SS-partial) or complete absence of the T6SS accounted for 12.3% (7/57). The partial deletions of the T6SS were categorized into three distinct types: (1) deletion of the tssH - tagX fragment while retaining the tssB - PAAR region (T6SS-partial 1); (2) deletion of the tssB - PAAR fragment while retaining the tssH - tagX region (T6SS-partial 2); and (3) deletion of the tssG - tagX fragment while retaining the tssB - tssF region (T6SS-partial 3). Effects of T6SS on natural transformation and bacterial competition A total of 16 strains were sensitive to kanamycin and selected for transformation and competition, among which 8 strains were classified as AB T6SS+ and eight as AB T6SS− . All kanamycin-sensitive strains demonstrated the ability to form biofilms, with a significant proportion (75%, 12/16) exhibiting low virulence or sensitivity to carbapenems (75.0%, 12/16). AB58 and AB68, which were carbapenem-sensitive (12.5%), low-virulence, and classified as AB T6SS− , were subjected to natural transformation. Transformation rates for these strains were 1.7×10 − 6 and 1.3×10 − 5 , respectively, indicating that A. baumannii possesses the capability to acquire exogenous resistance genes under natural conditions (Fig. 3 b). Bacterial competition assays demonstrated a significant reduction in the survival rate of TG1P when co-incubated with AB T6SS+ strains ( P = 0.0374), and demonstrated a greater competitive advantage over AB T6SS− strains (Fig. 3 c). However, the attempt to acquire the plasmid pBAV1K-T5-sfGFP through competitive transformation with TG1P was unsuccessful. Comparative genomic analysis and cell adhesion test CR-hvAB strains that shared the same ST type but exhibited distinct T6SS architectures (AB26 and AB51, AB41 and AB78) were selected for real-time single-molecule sequencing and comprehensive genomic analysis. Strains AB26 and AB51, as well as AB41 and AB78, were classified within related phylogenetic branches and AB26 and AB41 diverged and evolved from AB51 and AB78, respectively. There were 11 cg-SNPs between AB26 and AB51, and 24 cg-SNPs between AB41 and AB78. All four sequenced strains possessed a range of resistance genes, including aph(3'')-Ib , aph(3')-Ia , aph(6)-Id , armA , bla ADC−25 , bla OXA−23 , bla OXA−66 , bla TEM−1D , mph(E) , msr(E) , and tet(B) , as well as virulence genes such as abaI , bfmR , bfmS , csuA/B , csuC , csuD , csuE , and ompA . A comparative genomic analysis revealed variations among the four genomes in the regions encoding abaR , sul2 , T6SS, Pyrroloquinoline Quinone biosynthesis, Type I restriction-modification systems, RSF1010-like IncQ broad-host-range plasmids, and the Toxin-Antitoxin system HigAB (Fig. 4 ). Notably, the T6SS-deficient strains AB26 and AB41 may harbor the HigAB toxin-antitoxin system but lack the RSF1010-like IncQ plasmid and the sul2 gene. Comparative circular genome maps (Fig. 5 ) reveal widespread distribution of IS Aba1 and IS 26 insertion sequences. The bla OXA−23−like gene was located in a Tn 2006 transposon and the Tn 2006 - sul2 -Tn 2006 structure was identified in the genomes of both AB51 and AB78. The structural characteristics of T6SS gene clusters in the sequenced strains are illustrated in Fig. 6 a. Both AB26 and AB51 belonged to ST457, and the IS Aba13 insertion sequence was located at the same position. The T6SS in AB51 remained intact, whereas the T6SS in AB26 was truncated due to the IS Aba13 insertion, leading to the deletion of the PAAR-tssB fragment. The T6SS clusters in strains AB51 and AB78 were found to be structurally complete, with the only distinction being the presence of the IS Aba13 insertion sequence located upstream of the tssH gene in AB51. AB41 exhibited a deletion of about 17 kb downstream of IS Aba13 , leading to the complete absence of the T6SS. The adhesion rates of AB26 (ST457, T6SS with partial deletion), AB51 (ST457, complete T6SS with IS Aba13 ), AB41 (ST195, completely absent T6SS), and AB78 (ST195, complete T6SS) to BEAS-2B cells are presented in Fig. 6 b. A statistically significant difference in cell adhesion was observed between AB41 and AB78 at both the 2 h and 3h time points ( P 2h = 0.001315, P 3h = 0.006510). AB78 with complete T6SS and no insertion sequence exhibited a superior capacity for cell adhesion. Discussion A. baumannii is a significant pathogen associated with hospital-acquired infections and is frequently identified in cases of bacteremia. Bloodstream infections (BSIs) caused by multidrug-resistant A. baumannii (MDR-AB) are associated with high mortality rates and a propensity to progress to septic shock [ 26 ]. Recently, the emergence of hypervirulent strains of A. baumannii has further intensified the mortality risk for patients suffering from BSIs. This study collected A. baumannii strains isolated from blood samples between January 2017 and October 2020, with the aim of examining the clinical and molecular characteristics of hvAB and investigating the role of T6SS in the resistance and pathogenicity of A. baumannii . CR-AB is a significant pathogen in device-related hospital-acquired infections among ICU patients [ 27 ]. This study found a high ICU admission rate (80.1%) and significant differences between deceased and surviving patients in terms of prior IPM use, SCF use within 72 hours of infection, and MODS occurrence. Phylogenetic analysis categorized 38 CR-hvAB strains into three distinct clades, with six groups showing clonal transmission. Previous studies identified mortality risk factors in A. baumannii infections: advanced age, disease severity, complications, ICU admission, mechanical ventilation duration, prolonged hospitalization, antimicrobial therapy adverse events, MDR-AB infections, and bacterial co-infections [ 28 – 30 ]. AB-BSI 28-day mortality correlated with Acute Physiology and Chronic Health Evaluation II score (APACHE II) scores, shock, inadequate antimicrobial treatment, and carbapenem resistance [ 31 ]. ICU patients with A. baumannii infection had a 15.2-fold higher risk of subsequent infection and a 1.4-fold higher mortality risk [ 32 ]. Compared to general wards, ICUs facilitate pathogen transmission via frequent intubation, suboptimal disinfection, and inadequate infection control [ 33 ]. ICU patients' compromised health and immunity also increase vulnerability. Consequently, vigilant monitoring and management of AB-BSIs in ICUs are imperative, including environmental/equipment disinfection, pathogen surveillance, identifying at-risk patients, strict hand hygiene, sterile catheter techniques, and preventive isolation when needed [ 34 ]. In A. baumannii , the T6SS gene cluster structure includes core components like tssB , hcp ( tssD ), and tssM , with variable vgrG ( tssI ) copies/mutations [ 35 ]. AB T6SS⁺ strains show significantly increased antibiotic resistance. Deletion of tssB , hcp , or tssM alters antibiotic susceptibility, and tssM loss reduces biofilm formation [ 36 – 38 ]. Most study strains carried hcp and tssM . Compared to AB T6SS⁻ strains, AB T6SS⁺ exhibited higher antibiotic resistance and increased carriage of resistance genes ( bla OXA−23−like , bla TEM , adeB , adeR , adeS ). Structural T6SS variations were linked to the tssH gene. Repizo et al. [ 39 ] identified 191 Acinetobacter T6SS genes and proposed two transcription units ( tssB - PAAR ; tssH - tagX ), which may explain the genomic diversity. The T6SS is widely distributed in A. baumannii with a relatively conserved, variably sized structure. Strains with a complete T6SS may demonstrate enhanced antibiotic resistance. A. baumannii utilizes its T6SS to secrete effector proteins, killing competing bacteria and promoting horizontal gene transfer (HGT) via the release of extracellular DNA, thereby improving its ecological competitiveness [ 40 , 41 ]. In this study, AB T6SS+ significantly reduced E. coli TG1P populations when co-cultured, indicating enhanced competitive inhibition and host colonization ability. Similarly, Dong et al. [ 12 ] reported that wild-type A. baumanni i with functional T6SS effectively killed E. coli JM109P and acquired its antimicrobial resistance plasmid. Repizo et al. [ 35 ] confirmed T6SS activity in multiple strains, including ATCC 17978 and DSM30011. Additionally, A. baumannii exhibits antifungal activity through nucleases like TafE and T6e1 [ 42 , 43 ]. T6SS activation is thus crucial for adaptation to nutrient-limited and highly competitive environments. Whole-genome sequencing of four CR-hvAB strains revealed differences between ΔT6SS and intact-T6SS strains, particularly in the HigAB toxin-antitoxin system and RSF1010-like IncQ plasmids. The toxin-antitoxin system contributes to stress response, virulence, and tolerance, and promotes IncC plasmid stability in antibiotic-free environments, aiding bacterial survival [ 44 ]. The RSF1010-like IncQ plasmid has a broad host range and replicates stably across species [ 45 ]. Genomic analyses suggest that T6SS-deficient strains may adapt by upregulating alternative systems like toxin-antitoxin modules, while T6SS-intact strains utilize this system to acquire plasmids and resistance genes for competitive advantage. An upstream insertion sequence can modulate downstream gene expression either through its own promoter activity or by forming a hybrid promoter with adjacent sequences, thereby helping bacteria adapt to environmental changes. In AB26 and AB51, IS Aba13 was inserted at the tssH locus: AB26 carried a truncated insertion with partial loss, while AB51 remained intact. AB41 had a 17 kbp deletion covering the entire T6SS cluster after IS Aba13 . Adhesion to BEAS-2B cells ranked as: AB78 (intact T6SS, no insertion) > AB51 (intact T6SS with ISAba13) > AB26 (partial deletion) > AB41 (complete deletion). Pan et al. [ 46 ] reported reduced adhesion in an hcp deletion mutant, and Wang et al. [ 13 ] found that Δ vgrG showed impaired growth, adhesion, and virulence. Adams et al. [ 47 ] identified IS Aba13 in 22.4% of A. baumannii genomes; insertions of IS AJO2 /IS Aba13 in lpxA , lpxD , or pldA led to colistin dependence via altered membrane integrity and efflux expression [ 48 ]. An intact T6SS enhances adhesion and virulence, while IS Aba13 insertion may downregulate effector genes, suppressing T6SS activity and reducing pathogenicity and resistance. In conclusion, a high proportion of A. baumannii bloodstream infections demonstrate multidrug or extensive drug resistance and evidence of clonal spread. Both resistance and pathogenicity are closely linked to the T6SS, whose activity may be downregulated by IS Aba13 insertion, attenuating virulence and resistance profiles. Therefore, enhanced monitoring and infection control measures, particularly in ICUs, are urgently needed to limit its transmission. The T6SS represents a potential biomarker for assessing A. baumannii resistance and pathogenic potential. This study has several limitations. Due to experimental constraints, transformation experiments employed only kanamycin-sensitive strains, with a limited number of isolates. Certain analyses, including real-time single-molecule WGS and cell adhesion assays, were performed only on selected strains. Further mutant construction is required to clarify the precise role of IS Aba13 in T6SS-mediated resistance and pathogenicity. Abbreviations ICU intensive care unit MODS multiple organ dysfunction syndrome PICC peripherally inserted central venous catheter WBC white blood cell NEUT neutrophil granulocyte. Declarations Competing interests The authors declare no competing interests. Ethics declarations The study was approved by the Clinical Research Medical Ethics Subcommittee of the Medical Ethics Committee of Xiangya Hospital, Central South University (Approval No. 202209541) and adhered to the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from the participant included in the study. Funding This work was supported by the Natural Science Foundation of Hunan Province (No. 2022JJ70084, No. 2023JJ30900). Author Contribution Jun Li and Mengli Tang analyzed the data and wrote and edited the manuscript. Zhaojun Liu, Haolan Wang, and Yubing Xia carried out the experiments. Yongmei Hu, Haichen Wang and Fengjun Xia contributed to the methodology and data curation. Mingxiang Zou designed the project and revised the manuscript. All authors contributed to the article and approved the submitted version. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9192368","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":616700749,"identity":"a31ae82c-3635-4bd2-bb94-82d407455aa4","order_by":0,"name":"Jun Li","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Li","suffix":""},{"id":616700750,"identity":"37e1faff-84f4-4650-8b72-e1587d5fa27e","order_by":1,"name":"Mengli Tang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Mengli","middleName":"","lastName":"Tang","suffix":""},{"id":616700751,"identity":"2c44740d-25fc-4d00-ae5a-9bb0881cd092","order_by":2,"name":"Zhaojun Liu","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Zhaojun","middleName":"","lastName":"Liu","suffix":""},{"id":616700752,"identity":"a6417295-eb70-4bfa-884b-06279ccaefe1","order_by":3,"name":"Haolan Wang","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Haolan","middleName":"","lastName":"Wang","suffix":""},{"id":616700753,"identity":"027f6ddb-3dcb-4573-8c17-09817e227db5","order_by":4,"name":"Yubing Xia","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Yubing","middleName":"","lastName":"Xia","suffix":""},{"id":616700754,"identity":"8bff5b29-98fd-41f4-aa51-ace4d78fefc0","order_by":5,"name":"Yongmei Hu","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Yongmei","middleName":"","lastName":"Hu","suffix":""},{"id":616700755,"identity":"ed973911-b510-4cce-ab1a-e1378b5183eb","order_by":6,"name":"Haichen Wang","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Haichen","middleName":"","lastName":"Wang","suffix":""},{"id":616700756,"identity":"2fd08600-b997-4f45-8a7f-8eea95c16850","order_by":7,"name":"Fengjun Xia","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Fengjun","middleName":"","lastName":"Xia","suffix":""},{"id":616700757,"identity":"4284fe66-d1d2-45b0-aacf-b8c4886f0845","order_by":8,"name":"Mingxiang Zou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYLCCBCBmAzE+QPgGxGthnEG0Fhhg5iFGi3x7j+mGhztqE/vYzx5+bVNTl9jA3rxNgqHmDk4tjD1nzG4knjluzMaTl2adc+xwYgPPsTIJhmPPcLtFIgeope2YHBtDjplxbsOBxAagiARjw2GcWtigWnjY+N+YGVs2AB0m/wa/Fh6Ilho5oF7jx4wNzEBbePBrkQC6HKjlgDGbxBszxp5jh43beNKKLRKO4dYi39687ebPtrrE+f05xh9+1NTJ9rMf3njjQw1uLVBwGOIvMAkiEghpYGCoAxHMHwgrHAWjYBSMgpEIAMjHUeYMcVLZAAAAAElFTkSuQmCC","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":true,"prefix":"","firstName":"Mingxiang","middleName":"","lastName":"Zou","suffix":""}],"badges":[],"createdAt":"2026-03-22 15:41:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9192368/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9192368/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106300352,"identity":"aea6fbee-dd6b-4460-943e-14b30cc98404","added_by":"auto","created_at":"2026-04-07 09:13:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":509144,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHvAB isolated from blood samples\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Virulence genes are color-coded, and the numbers of strains are shown. b. Kaplan-meier survival curves. The survival rates of larvae infected with AB41, AB61, AB74, AB78, AB107 and AB130 were significantly lower than that of ATCC 19606 (100.0%). c. Biofilm formation ability compared between hvAB and non-hvAB strains (\u003cem\u003eP\u003c/em\u003e= 0.0137).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/b67a6ed77cafa582497604b7.png"},{"id":106300004,"identity":"4a739db8-f176-409f-bdbc-708318d88ae6","added_by":"auto","created_at":"2026-04-07 09:12:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1573600,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe phylogenetic tree, ST type, T6SS classification, virulence factors, and resistance genes of CR-hvAB\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplete: intact T6SS structure; Missing: T6SS absent; Partial: partially deleted. Dark blue boxes indicate the presence of respective genes, and strains within the same clade are color-coded accordingly. The genome of \u003cem\u003eA. baumannii\u003c/em\u003e strain 2018BJAB2 (GenBank accession no. NZ_CP059350.1) was used as the reference for cg-SNPs analysis.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/8913cdb8b0fb7f95cb41a840.png"},{"id":106300059,"identity":"95737a7e-d365-4a8c-8272-4aba3aa22045","added_by":"auto","created_at":"2026-04-07 09:12:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":7174032,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe composition of T6SS and its function in plasmid transfer and interbacterial competition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. “T6SS-complete” indicates an intact T6SS gene cluster; “T6SS-partial” indicates a partially deleted cluster. Genes are depicted as arrows colored according to their function. b. Transformation efficiency and PCR verification. Lane M: DL2000 DNA marker; Lane 1~2: successfully transformed strains AB58 and AB68 carrying pBAV1K-T5-sfGFP; Lane 3: plasmid positive control; Lane 4: TG1 negative control; Lane 5: untransformed strains. c. Competition assay between \u003cem\u003eE. coli\u003c/em\u003e TG1P and AB\u003csup\u003eT6SS+\u003c/sup\u003e (a) or AB\u003csup\u003eT6SS-\u003c/sup\u003e (b). The y-axis represents viable TG1P counts after co-culture. *\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/3c6bd7f4e66eab6eb7df6260.png"},{"id":106300070,"identity":"debfe2c4-8e64-4c6d-99b1-4f892f6c7a96","added_by":"auto","created_at":"2026-04-07 09:12:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":831630,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparative analysis of strains based on long-read sequencing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePresent: complete or present gene; likely: probable but unconfirmed gene; absent: gene not detected.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/e2e58d66ae861f838b52e152.png"},{"id":106300334,"identity":"274e3272-89a6-4066-bfef-aa281a908a0a","added_by":"auto","created_at":"2026-04-07 09:13:11","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2311245,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparing genome circles of strains based on long-read sequencing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe concentric circles in the figure represent GC content and GC skew. Reference genome 2018BJAB2 (ST195, T6SS-complete) is shown alongside strains AB26 (ST457, T6SS-partial), AB51 (ST457, T6SS-complete), AB41 (ST195, T6SS-absent), and AB78 (ST195, T6SS-complete). Resistance and virulence genes are labeled in red, T6SS components in blue, and insertion sequences in black.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/6ea2d9373c1ecff095b898c0.png"},{"id":106300037,"identity":"dd2ab489-532c-425e-9a24-32f73f59d85d","added_by":"auto","created_at":"2026-04-07 09:12:18","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1097179,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eT6SS gene cluster structure and cell adhesion ability in the sequenced strains\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Distribution of the insertion sequence IS\u003cem\u003eAba13\u003c/em\u003e within the T6SS gene cluster varied among strains: AB51 (ST457, T6SS-complete with IS\u003cem\u003eAba13\u003c/em\u003e), AB26 (ST457, T6SS-partial), AB78 (ST195, T6SS-complete), and AB41 (ST195, T6SS-absent).\u003c/p\u003e\n\u003cp\u003eb. Cell adhesion capacity was assessed across T6SS-defined strain types. **\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/21250e7bb7139d4b8caf12d7.png"},{"id":106300535,"identity":"42ea6e65-9e3b-4fad-bb2f-4417680f579f","added_by":"auto","created_at":"2026-04-07 09:14:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14990621,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/6810e6b7-f4b4-4bb5-a4a2-a1cd2239514a.pdf"},{"id":106299999,"identity":"bb48ef9c-9bf7-4aa5-9c11-3ae8af1e8147","added_by":"auto","created_at":"2026-04-07 09:12:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":160767,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial0322.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9192368/v1/4da29a54c118611065a8259b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of Type VI Secretion System in resistance and pathogenicity of Acinetobacter baumannii","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e, recognized as a significant pathogen associated with nosocomial infections, has exhibited a growing resistance to antibiotics in recent years, with the emergence of strains resistant to polymyxins [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Due to its critical issue of drug resistance, it has been classified as a critical priority pathogen in the recently released list of bacterial priority pathogens by World Health Organization (WHO) (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.WHO.int/publications/i/item/9789240093461\u003c/span\u003e\u003cspan address=\"https://www.WHO.int/publications/i/item/9789240093461\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Recent studies have identified a virulence-enhancing strain of \u003cem\u003eA. baumannii\u003c/em\u003e, referred to as hypervirulent \u003cem\u003eA. baumannii\u003c/em\u003e (hvAB). This strain has been shown to have a higher propensity to cause infections in immunocompromised patients, resulting in an increased mortality rate associated with bloodstream infections [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Type VI secretion system (T6SS) is a multi-component transmembrane apparatus that relies on cell-to-cell contact and is prevalent among various gram-negative bacteria, including \u003cem\u003eVibrio cholerae\u003c/em\u003e, \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e, \u003cem\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003eA. baumannii\u003c/em\u003e, and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e. The T6SS gene cluster is comprised of 13 conserved core genes (\u003cem\u003etss\u003c/em\u003e genes), T6SS-related genes (\u003cem\u003etag\u003c/em\u003e genes) and T6SS effector genes (\u003cem\u003etse\u003c/em\u003e genes) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Bacteria utilize T6SS to secrete a variety of effector proteins, fulfilling various biological functions. These functions include roles in pathogenicity, the recognition of foreign species, the uptake of metal ions, the formation of biofilms, and responses to environmental stressors [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent research has indicated a potential correlation between T6SS and antimicrobial resistance and virulence of bacteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. An \u003cem\u003ehcp\u003c/em\u003e-deletion mutant demonstrated a significantly diminished capacity to acquire resistance plasmids from \u003cem\u003eE. coli\u003c/em\u003e JM109P [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and the \u003cem\u003evgrG\u003c/em\u003e-deletion variant of \u003cem\u003eA. baumannii\u003c/em\u003e exhibited enhanced resistance to ampicillin-sulbactam (SAM), a diminished growth rate, impaired adhesion to eukaryotic cells, and reduced virulence in murine infection models [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nevertheless, the role of T6SS in mediating resistance and pathogenicity in \u003cem\u003eA. baumannii\u003c/em\u003e is poorly understood.\u003c/p\u003e \u003cp\u003eIn this study, we collected clinical isolates of \u003cem\u003eA. baumannii\u003c/em\u003e from blood samples and identified hvAB. We compared drug resistance, virulence, plasmid conjugation, transformation, bacterial competition, and cell adhesion between T6SS-positive strains (AB\u003csup\u003eT6SS+\u003c/sup\u003e) and T6SS-negative strains (AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e) in order to clarify the role of T6SS in the resistance and pathogenicity of \u003cem\u003eA. baumannii\u003c/em\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBacterial strains and clinical data\u003c/h2\u003e \u003cp\u003eNon-repetitive \u003cem\u003eA. baumannii\u003c/em\u003e strains were collected from blood samples at Xiangya Hospital of Central South University between January 2017 and October 2020. The strains were re-identified using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS; Bruker Daltonics GmbH, Germany) and 16S rRNA sequencing, using \u003cem\u003eE. coli\u003c/em\u003e ATCC 25922 (National Center for Clinical Laboratories, China) as the quality control strain. Clinical data were collected, including sex, age, department, pre-existing medical conditions, complications, antibiotic administration, invasive procedures, etc.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAntimicrobial susceptibility testing\u003c/h3\u003e\n\u003cp\u003eAntimicrobial susceptibility testing was conducted utilizing the micro-broth dilution method (Wenzhou Kont Biotechnology Company, China). The determination of susceptibility results was guided by the Clinical and Laboratory Standards Institute (CLSI) 2022 criteria [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. TGC was determined according to the Food and Drug Administration (FDA) breakpoint.\u003c/p\u003e\n\u003ch3\u003eIdentification of resistance genes, virulence genes, and core genes of T6SS\u003c/h3\u003e\n\u003cp\u003eGenes associated with resistance, virulence, and the core components T6SS (\u003cem\u003ehcp\u003c/em\u003e, \u003cem\u003etssM\u003c/em\u003e) were identified using polymerase chain reaction (PCR). The specific primers along with the PCR conditions were established based on prior research [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A detailed compilation of genes and primers is available in Supplementary Material S1 Table.\u003c/p\u003e\n\u003ch3\u003eBiofilm formation assay\u003c/h3\u003e\n\u003cp\u003eBiofilm formation was assessed by crystal violet staining method [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The strains were prepared in a suspension of 1.0\u0026times;10\u003csup\u003e8\u003c/sup\u003e CFU/mL, subsequently diluted and cultured in a 96-well plate (3 parallel wells for each strain) at 37\u0026deg;C for 24 h, then stained with 1% crystal violet, and decolorized with 95% ethanol. The optical density (OD) was measured at a wavelength of 570 nm (OD\u003csub\u003e570\u003c/sub\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eGalleria mellonella\u003c/b\u003e \u003cb\u003einfection model\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe assay was modified based on a previous study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. \u003cem\u003eG. mellonella\u003c/em\u003e larvae (Tianjin Huiyude Biotechnology Company, China) were randomly selected and allocated into groups of ten. The strains were prepared into 1.0\u0026times;10\u003csup\u003e7\u003c/sup\u003e CFU/mL suspension with PBS. Each larva received an injection of 10 \u0026micro;L of the bacterial suspension and incubated at 37\u0026deg;C in the dark for 5 days. Mortality was monitored and recorded at 24-hour intervals. The strains AB5075 and \u003cem\u003eA. baumannii\u003c/em\u003e ATCC 19606 served as controls for high and low virulence, respectively.\u003c/p\u003e\n\u003ch3\u003eWhole-genome sequencing (WGS) and data analysis\u003c/h3\u003e\n\u003cp\u003eGenomic DNA was extracted using the TIANamp Bacteria DNA Kit (TIANGEN Biotech, China). Sequencing was performed on the Novaseq 6000 and PromethION platforms. Multilocus sequence typing (MLST) was analyzed via PubMLST. Core genomes single-nucleotide polymorphisms (cg-SNPs) were called with Snippy and used for phylogenetic reconstruction. Resistance and virulence genes were identified using Comprehensive Antibiotic Resistance Database (CARD) and Virulence Factor Database (VFDB), respectively. Phylogenetic trees were visualized with ChiPlot. Genome annotation was performed with RAST 2.0. Plasmid types and insertion sequences were predicted using Plasmid MLST and IS Finder, respectively. Comparative genomics and T6SS cluster variations were analyzed with BRIG [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Easyfig [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The data supporting this study's findings are openly available in the NCBI BioProject repository under BioProject accession number PRJNA1206144.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNatural transformation, bacterial competence and competitive transformation\u003c/h2\u003e \u003cp\u003eThe micro-broth dilution method was used to identify kanamycin-sensitive strains for use in natural transformation, bacterial competence, and competitive transformation assays. Assay was modified based on previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNatural transformation: Strains were prepared into 1.5\u0026times;10\u003csup\u003e8\u003c/sup\u003e CFU/mL suspension. A volume of 10 \u0026micro;L of the bacterial suspension was combined with 10 \u0026micro;L of the plasmid pBAV1K-T5-sfGFP (Abiowell Biotechnology Co., Ltd., Changsha, China), which contains a kanamycin resistance gene. This mixture was inoculated onto motility medium (MM) plates and incubated at 37\u0026deg;C overnight. Colonies were counted and the pBAV1K-T5-sfGFP plasmid was confirmed through PCR.\u003c/p\u003e \u003cp\u003eBacterial competence: The pBAV1K-T5-sfGFP plasmid carrying a kanamycin resistance gene was transformed into \u003cem\u003eE. coli\u003c/em\u003e strain TG1, generating the strain named TG1P. \u003cem\u003eA. baumannii\u003c/em\u003e strains and TG1P were prepared into 1.5\u0026times;10\u003csup\u003e8\u003c/sup\u003e CFU/mL suspension. 100 \u0026micro;L of TG1P was combined with 10 \u0026micro;L of \u003cem\u003eA. baumannii\u003c/em\u003e, and a 10 \u0026micro;L aliquot of this mixture was applied to an LB agar plate then incubated at 37℃ for 24 h. LB agar supplemented with kanamycin was used to select for viable \u003cem\u003eE. coli\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eCompetitive transformation: \u003cem\u003eA. baumannii\u003c/em\u003e strains and TG1P were prepared into 1.5\u0026times;10\u003csup\u003e8\u003c/sup\u003e CFU/mL suspension. A 20 \u0026micro;L mixture was prepared at an \u003cem\u003eA. baumannii\u003c/em\u003e to \u003cem\u003eE. coli\u003c/em\u003e (AB:EC) ratio of 1:9, and 7 \u0026micro;L of this mixture was inoculated onto MM plates then incubated at 37\u0026deg;C overnight. LB agar supplemented with kanamycin and ampicillin was used to select for \u003cem\u003eA. baumannii\u003c/em\u003e that acquired the pBAV1K-T5-sfGFP plasmid from TG1P. Colonies were enumerated to determine the conversion rates.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCell adhesion\u003c/h3\u003e\n\u003cp\u003eHuman normal lung epithelial cells BEAS-2B (from the research group of Professor Pinhua Pan, Xiangya Hospital, Central South University) were used as infected cells. \u003cem\u003eA. baumannii\u003c/em\u003e was introduced at a multiplicity of infection (MOI) of 50. After BEAS-2B cells infected with \u003cem\u003eA. baumannii\u003c/em\u003e for durations of 1, 2, and 3 h, unattached bacteria were removed, and cells were lysed, the number of bacteria adhering to the BEAS-2B cells were counted. Adhesion rate = (number of counted colonies \u0026times; dilution factor) / (number of bacteria inoculated in the wells) \u0026times; 100%.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eClinical features of patients with bloodstream infections caused by\u003c/b\u003e \u003cb\u003eA. baumannii\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 136 strains of \u003cem\u003eA. baumannii\u003c/em\u003e were isolated from patients diagnosed with bloodstream infections. The predominant demographic consisted of male patients, accounting for 77.2% (105/136), with a mean age of 49.5 years (33.0\u0026ndash;60.0). The majority of these patients were admitted to the departments of critical care medicine (49.3%, 67/136) and burn surgery (13.2%, 18/136). The primary complications observed included pulmonary infections (64.0%, 87/136), hepatobiliary diseases (38.2%, 52/136), urinary system diseases (35.3%, 48/136), septic shock (33.1%, 45/136), multiple organ dysfunction syndrome (MODS, 27.9%, 38/136), hypertension (21.3%, 29/136), and severe pneumonia (20.6%, 28/136). Prior to the identification of \u003cem\u003eA. baumannii\u003c/em\u003e bloodstream infections, 128 patients (94.1%) had received antibiotic treatment, 127 patients (93.4%) had indwelling catheters or had undergone invasive procedures, and 101 patients (74.3%) had been treated in the intensive care unit (ICU). Following the onset of \u003cem\u003eA. baumannii\u003c/em\u003e bloodstream infections, 109 patients (80.1%) received ICU treatment. Among the cohort, 45 patients (33.1%) did not recover, 43 patients (31.6%) died, and 35 patients (25.7%) died within 30 days of the \u003cem\u003eA. baumannii\u003c/em\u003e bloodstream infection diagnosis.\u003c/p\u003e \u003cp\u003eNotable differences were observed in the use of imipenem (IPM) prior to infection (44.2% in deceased patients versus 23.7% in survivors, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015268), the administration of cefoperazone/sulbactam (SCF) within 72 h post-infection (18.6% in deceased patients compared to 46.2% in survivors, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001968), and the incidence of MODS (39.5% in deceased patients vs. 22.6% in survivors, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.040473) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical characteristics between deceased and surviving patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDeath (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eSurvival (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.0 (35\u0026thinsp;~\u0026thinsp;61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.0 (31\u0026thinsp;~\u0026thinsp;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.575826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.428404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepartment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCritical care medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.763368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurn surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.866536\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory internal medicine ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.845481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.487357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMODS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.040473*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.708334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.946525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.775984\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.364870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU treatment during hospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.226331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of days in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0 (11.0\u0026thinsp;~\u0026thinsp;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0 (13.0\u0026thinsp;~\u0026thinsp;51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.289019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU treatment before infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (2.0\u0026thinsp;~\u0026thinsp;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0 (0.0\u0026thinsp;~\u0026thinsp;12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.268897\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of antibiotics before infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.077844\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.015268*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone/sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.676943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTigecycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.982373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInvasive procedures before infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral venous catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.689347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.487357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvasive mechanical ventilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.868479\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial catheterization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.434498\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePICC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.130948\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntibiotics used within 72 h of infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone/sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001968*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.091438\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTigecycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.818618\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.685520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5 (4.4\u0026thinsp;~\u0026thinsp;13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.1 (6.2\u0026thinsp;~\u0026thinsp;15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.317672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNEUT%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.3 (72.2\u0026thinsp;~\u0026thinsp;93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.1 (77.5\u0026thinsp;~\u0026thinsp;94.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.644793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: *\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of hvAB strains and clinical features of patients infected with hvAB\u003c/h2\u003e \u003cp\u003eThe detection rates for the genes \u003cem\u003eompA\u003c/em\u003e, \u003cem\u003ebap\u003c/em\u003e, \u003cem\u003eabaI\u003c/em\u003e, \u003cem\u003ecsuE\u003c/em\u003e, and \u003cem\u003ebfmS\u003c/em\u003e are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea. Based on the criteria from the literature, strains that possessed multiple common virulence-associated genes and exhibited 3-day mortality rates of 80% or greater in infected \u003cem\u003eG. mellonella\u003c/em\u003e, and whose patients either failed to recover or died during hospitalization, were classified as hvAB (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, a total of 40 (29.4%) strains were identified as hvAB.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThirty-eight strains (95%) of hvAB were identified as carbapenem-resistant hypervirulent \u003cem\u003eA. baumannii\u003c/em\u003e (CR-hvAB). The comparative characteristics of hvAB and non-hvAB strains are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In contrast to non-hvAB strains, hvAB exhibited a significantly higher prevalence of the virulence gene \u003cem\u003eabaI\u003c/em\u003e (92.5% vs. 76.0%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026147) and a lower prevalence of the outer membrane protein-associated resistance gene \u003cem\u003ecarO\u003c/em\u003e (77.5% vs. 90.6%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039585). However, the capacity for biofilm formation was diminished in hvAB strains (55.0% vs. 34.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025543, as illustrated by the OD value in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative characteristics of hvAB and non-hvAB strains\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ehvAB(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003enon-hvAB(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResistance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.396920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.396920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefepime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.316438\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.178136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.396920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.532438\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGentamicin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.256987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmikacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.131038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobramycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.809941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin/tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.396920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone/sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.172009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTigecycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.555165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo/weak film formation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.025543*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVirulence-related genes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eompA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebfmS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.111776\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecsuE\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.085931\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eabaI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.026147*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebap\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.323236\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResistance genes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.749485\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.051434\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u0026minus;1\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.555165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecarO\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.039585*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeB\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeE\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeG\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeJ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.451587\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeR\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.808329\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.321194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eabeM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: *\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, patients infected with hvAB exhibited a significantly higher incidence of severe pneumonia, with rates of 35.0% compared to 14.6% in those with non-hvAB (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007295). Conversely, patients with non-hvAB infection demonstrated a greater prevalence of concurrent tumors, with 21.9% compared to 7.5% in the hvAB-infected group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045104).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical characteristics in patients with hvAB versus non-hvAB infections\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ehvAB(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eNon-hvAB (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.0 (21.5\u0026thinsp;~\u0026thinsp;55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.0 (37.0\u0026thinsp;~\u0026thinsp;61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.055373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.957909\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepartment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCritical care medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.626159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurn surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.870253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory internal medicine ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.358911\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.344450\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.268826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMODS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.729797\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.007295*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.045104*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.807815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.569327\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal days in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.5 (14.8\u0026thinsp;~\u0026thinsp;37.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0 (13.0\u0026thinsp;~\u0026thinsp;44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.730885\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU treatment before infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.761231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of antibiotics before infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.857194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.106035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone/sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.699515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTigecycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.434430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInvasive procedures before infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral venous catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.411866\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.480306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvasive mechanical ventilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.739565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial catheterization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.734326\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePICC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.430545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo improvement after 72 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.960320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath during hospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.174768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: *\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: ICU, intensive care unit; MODS, multiple organ dysfunction syndrome; PICC, peripherally inserted central venous catheter.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGenetic and phylogenetic analysis of CR-hvAB\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the phylogenetic tree, ST types, T6SS classifications, virulence factors, and resistance genes of the CR-hvAB strains. The predominant sequence types identified were ST457 (12/38, 31.6%) and ST195 (8/38, 21.1%). A variety of resistance genes were identified. All CR-hvAB isolates were found to possess virulence-associated genes including \u003cem\u003eompA\u003c/em\u003e, \u003cem\u003eabaR\u003c/em\u003e, \u003cem\u003ebap\u003c/em\u003e, \u003cem\u003ebfmR\u003c/em\u003e, and \u003cem\u003ebfmS\u003c/em\u003e. The CR-hvAB isolates obtained from patients with \u003cem\u003eA. baumannii\u003c/em\u003e bloodstream infections (AB-BSI) were categorized into three distinct clades, with strains of the same sequence type exhibiting close genetic relationships.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eVariations in cg-SNPs between the two strains of CR-hvAB were found to range from 0 to 131. Notably, the number of cg-SNP variations among six designated groups was \u0026le;\u0026thinsp;8. These strains are considered closely related in a clinical context and may originate from the same transmission chain [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe association between T6SS and the resistance and virulence\u003c/h2\u003e \u003cp\u003eAmong 136 \u003cem\u003eA. baumannii\u003c/em\u003e strains, 116 (85.3%) were found to possess \u003cem\u003ehcp\u003c/em\u003e and \u003cem\u003etssM\u003c/em\u003e genes. Compared with AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e, AB\u003csup\u003eT6SS+\u003c/sup\u003e exhibited significantly higher resistance rates to the majority of commonly used antibiotics (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The prevalence of gene \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e, gene \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, the efflux pump genes \u003cem\u003eadeB\u003c/em\u003e, \u003cem\u003eadeR\u003c/em\u003e, \u003cem\u003eadeS\u003c/em\u003e, and the virulence-associated gene \u003cem\u003ecsuE\u003c/em\u003e were also significantly greater in AB\u003csup\u003eT6SS+\u003c/sup\u003e (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of characteristics of AB\u003csup\u003eT6SS+\u003c/sup\u003e and AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAB\u003csup\u003eT6SS+\u003c/sup\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResistance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefepime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000015*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.104450\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGentamicin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000288*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmikacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000149*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobramycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000537*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin/tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone/sulbactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.045098*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo/weak film formation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.741039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehypervirulence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.639171\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVirulence-related genes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eompA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebfmS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.591808\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecsuE\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000009*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eabaI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.099363\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebap\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.071346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResistance genes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001014*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000068*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eNDM\u0026minus;1\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.020697*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ecarO\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.125025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeB\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.020697*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeE\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeG\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.103007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeJ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.628220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeR\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.004346*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eadeS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001605*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eabeM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: *\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGenomic characteristics of strains based on long-read sequencing\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT6SS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eST\u003c/p\u003e \u003cp\u003etype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGenome size (bp)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eG\u0026thinsp;+\u0026thinsp;C (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCDS (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePlasmid number (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMEGs (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAB26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartially absent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,972,415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAB51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,950,629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAB41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompletely absent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,996,747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAB78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4,059,951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eAbbreviations: G\u0026thinsp;+\u0026thinsp;C, G and C bases; CDS, coding sequence; MEGs, mobile genetic elements.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 57 strains, comprising 38 CR-hvAB strains and 19 non-hvAB strains with various ST types, were selected for sequencing the T6SS structure. T6SS of \u003cem\u003eA. baumannii\u003c/em\u003e exhibited a relatively conserved nature. The majority of the T6SS structures were found to be complete, designated as T6SS-1A (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, T6SS-complete), which constituted 75.4% (43/57) of the strains. Strains exhibiting partial deletion (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, T6SS-partial) or complete absence of the T6SS accounted for 12.3% (7/57). The partial deletions of the T6SS were categorized into three distinct types: (1) deletion of the \u003cem\u003etssH\u003c/em\u003e-\u003cem\u003etagX\u003c/em\u003e fragment while retaining the \u003cem\u003etssB\u003c/em\u003e-\u003cem\u003ePAAR\u003c/em\u003e region (T6SS-partial 1); (2) deletion of the \u003cem\u003etssB\u003c/em\u003e-\u003cem\u003ePAAR\u003c/em\u003e fragment while retaining the \u003cem\u003etssH\u003c/em\u003e-\u003cem\u003etagX\u003c/em\u003e region (T6SS-partial 2); and (3) deletion of the \u003cem\u003etssG\u003c/em\u003e-\u003cem\u003etagX\u003c/em\u003e fragment while retaining the \u003cem\u003etssB\u003c/em\u003e-\u003cem\u003etssF\u003c/em\u003e region (T6SS-partial 3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEffects of T6SS on natural transformation and bacterial competition\u003c/h2\u003e \u003cp\u003eA total of 16 strains were sensitive to kanamycin and selected for transformation and competition, among which 8 strains were classified as AB\u003csup\u003eT6SS+\u003c/sup\u003e and eight as AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e. All kanamycin-sensitive strains demonstrated the ability to form biofilms, with a significant proportion (75%, 12/16) exhibiting low virulence or sensitivity to carbapenems (75.0%, 12/16).\u003c/p\u003e \u003cp\u003eAB58 and AB68, which were carbapenem-sensitive (12.5%), low-virulence, and classified as AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e, were subjected to natural transformation. Transformation rates for these strains were 1.7\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e and 1.3\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;5\u003c/sup\u003e, respectively, indicating that \u003cem\u003eA. baumannii\u003c/em\u003e possesses the capability to acquire exogenous resistance genes under natural conditions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). Bacterial competition assays demonstrated a significant reduction in the survival rate of TG1P when co-incubated with AB\u003csup\u003eT6SS+\u003c/sup\u003e strains (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0374), and demonstrated a greater competitive advantage over AB\u003csup\u003eT6SS\u0026minus;\u003c/sup\u003e strains (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). However, the attempt to acquire the plasmid pBAV1K-T5-sfGFP through competitive transformation with TG1P was unsuccessful.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComparative genomic analysis and cell adhesion test\u003c/h2\u003e \u003cp\u003eCR-hvAB strains that shared the same ST type but exhibited distinct T6SS architectures (AB26 and AB51, AB41 and AB78) were selected for real-time single-molecule sequencing and comprehensive genomic analysis. Strains AB26 and AB51, as well as AB41 and AB78, were classified within related phylogenetic branches and AB26 and AB41 diverged and evolved from AB51 and AB78, respectively. There were 11 cg-SNPs between AB26 and AB51, and 24 cg-SNPs between AB41 and AB78.\u003c/p\u003e \u003cp\u003eAll four sequenced strains possessed a range of resistance genes, including \u003cem\u003eaph(3'')-Ib\u003c/em\u003e, \u003cem\u003eaph(3')-Ia\u003c/em\u003e, \u003cem\u003eaph(6)-Id\u003c/em\u003e, \u003cem\u003earmA\u003c/em\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eADC\u0026minus;25\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;66\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u0026minus;1D\u003c/sub\u003e, \u003cem\u003emph(E)\u003c/em\u003e, \u003cem\u003emsr(E)\u003c/em\u003e, and \u003cem\u003etet(B)\u003c/em\u003e, as well as virulence genes such as \u003cem\u003eabaI\u003c/em\u003e, \u003cem\u003ebfmR\u003c/em\u003e, \u003cem\u003ebfmS\u003c/em\u003e, \u003cem\u003ecsuA/B\u003c/em\u003e, \u003cem\u003ecsuC\u003c/em\u003e, \u003cem\u003ecsuD\u003c/em\u003e, \u003cem\u003ecsuE\u003c/em\u003e, and \u003cem\u003eompA\u003c/em\u003e. A comparative genomic analysis revealed variations among the four genomes in the regions encoding \u003cem\u003eabaR\u003c/em\u003e, \u003cem\u003esul2\u003c/em\u003e, T6SS, Pyrroloquinoline Quinone biosynthesis, Type I restriction-modification systems, RSF1010-like IncQ broad-host-range plasmids, and the Toxin-Antitoxin system HigAB (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Notably, the T6SS-deficient strains AB26 and AB41 may harbor the HigAB toxin-antitoxin system but lack the RSF1010-like IncQ plasmid and the \u003cem\u003esul2\u003c/em\u003e gene.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComparative circular genome maps (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) reveal widespread distribution of IS\u003cem\u003eAba1\u003c/em\u003e and IS\u003cem\u003e26\u003c/em\u003e insertion sequences. The \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e gene was located in a Tn\u003cem\u003e2006\u003c/em\u003e transposon and the Tn\u003cem\u003e2006\u003c/em\u003e-\u003cem\u003esul2\u003c/em\u003e-Tn\u003cem\u003e2006\u003c/em\u003e structure was identified in the genomes of both AB51 and AB78.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe structural characteristics of T6SS gene clusters in the sequenced strains are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ea. Both AB26 and AB51 belonged to ST457, and the IS\u003cem\u003eAba13\u003c/em\u003e insertion sequence was located at the same position. The T6SS in AB51 remained intact, whereas the T6SS in AB26 was truncated due to the IS\u003cem\u003eAba13\u003c/em\u003e insertion, leading to the deletion of the \u003cem\u003ePAAR-tssB\u003c/em\u003e fragment. The T6SS clusters in strains AB51 and AB78 were found to be structurally complete, with the only distinction being the presence of the IS\u003cem\u003eAba13\u003c/em\u003e insertion sequence located upstream of the \u003cem\u003etssH\u003c/em\u003e gene in AB51. AB41 exhibited a deletion of about 17 kb downstream of IS\u003cem\u003eAba13\u003c/em\u003e, leading to the complete absence of the T6SS.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe adhesion rates of AB26 (ST457, T6SS with partial deletion), AB51 (ST457, complete T6SS with IS\u003cem\u003eAba13\u003c/em\u003e), AB41 (ST195, completely absent T6SS), and AB78 (ST195, complete T6SS) to BEAS-2B cells are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eb. A statistically significant difference in cell adhesion was observed between AB41 and AB78 at both the 2 h and 3h time points (\u003cem\u003eP\u003c/em\u003e\u003csub\u003e2h\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.001315, \u003cem\u003eP\u003c/em\u003e\u003csub\u003e3h\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.006510). AB78 with complete T6SS and no insertion sequence exhibited a superior capacity for cell adhesion.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cem\u003eA. baumannii\u003c/em\u003e is a significant pathogen associated with hospital-acquired infections and is frequently identified in cases of bacteremia. Bloodstream infections (BSIs) caused by multidrug-resistant \u003cem\u003eA. baumannii\u003c/em\u003e (MDR-AB) are associated with high mortality rates and a propensity to progress to septic shock [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Recently, the emergence of hypervirulent strains of \u003cem\u003eA. baumannii\u003c/em\u003e has further intensified the mortality risk for patients suffering from BSIs. This study collected \u003cem\u003eA. baumannii\u003c/em\u003e strains isolated from blood samples between January 2017 and October 2020, with the aim of examining the clinical and molecular characteristics of hvAB and investigating the role of T6SS in the resistance and pathogenicity of \u003cem\u003eA. baumannii\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eCR-AB is a significant pathogen in device-related hospital-acquired infections among ICU patients [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This study found a high ICU admission rate (80.1%) and significant differences between deceased and surviving patients in terms of prior IPM use, SCF use within 72 hours of infection, and MODS occurrence. Phylogenetic analysis categorized 38 CR-hvAB strains into three distinct clades, with six groups showing clonal transmission. Previous studies identified mortality risk factors in \u003cem\u003eA. baumannii\u003c/em\u003e infections: advanced age, disease severity, complications, ICU admission, mechanical ventilation duration, prolonged hospitalization, antimicrobial therapy adverse events, MDR-AB infections, and bacterial co-infections [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. AB-BSI 28-day mortality correlated with Acute Physiology and Chronic Health Evaluation II score (APACHE II) scores, shock, inadequate antimicrobial treatment, and carbapenem resistance [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. ICU patients with \u003cem\u003eA. baumannii\u003c/em\u003e infection had a 15.2-fold higher risk of subsequent infection and a 1.4-fold higher mortality risk [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Compared to general wards, ICUs facilitate pathogen transmission via frequent intubation, suboptimal disinfection, and inadequate infection control [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. ICU patients' compromised health and immunity also increase vulnerability. Consequently, vigilant monitoring and management of AB-BSIs in ICUs are imperative, including environmental/equipment disinfection, pathogen surveillance, identifying at-risk patients, strict hand hygiene, sterile catheter techniques, and preventive isolation when needed [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn \u003cem\u003eA. baumannii\u003c/em\u003e, the T6SS gene cluster structure includes core components like \u003cem\u003etssB\u003c/em\u003e, \u003cem\u003ehcp\u003c/em\u003e (\u003cem\u003etssD\u003c/em\u003e), and \u003cem\u003etssM\u003c/em\u003e, with variable \u003cem\u003evgrG\u003c/em\u003e (\u003cem\u003etssI\u003c/em\u003e) copies/mutations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. AB\u003csup\u003eT6SS⁺\u003c/sup\u003e strains show significantly increased antibiotic resistance. Deletion of \u003cem\u003etssB\u003c/em\u003e, \u003cem\u003ehcp\u003c/em\u003e, or \u003cem\u003etssM\u003c/em\u003e alters antibiotic susceptibility, and \u003cem\u003etssM\u003c/em\u003e loss reduces biofilm formation [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Most study strains carried \u003cem\u003ehcp\u003c/em\u003e and \u003cem\u003etssM\u003c/em\u003e. Compared to AB\u003csup\u003eT6SS⁻\u003c/sup\u003e strains, AB\u003csup\u003eT6SS⁺\u003c/sup\u003e exhibited higher antibiotic resistance and increased carriage of resistance genes (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, \u003cem\u003eadeB\u003c/em\u003e, \u003cem\u003eadeR\u003c/em\u003e, \u003cem\u003eadeS\u003c/em\u003e). Structural T6SS variations were linked to the \u003cem\u003etssH\u003c/em\u003e gene. Repizo et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] identified 191 \u003cem\u003eAcinetobacter\u003c/em\u003e T6SS genes and proposed two transcription units (\u003cem\u003etssB\u003c/em\u003e-\u003cem\u003ePAAR\u003c/em\u003e; \u003cem\u003etssH\u003c/em\u003e-\u003cem\u003etagX\u003c/em\u003e), which may explain the genomic diversity. The T6SS is widely distributed in \u003cem\u003eA. baumannii\u003c/em\u003e with a relatively conserved, variably sized structure. Strains with a complete T6SS may demonstrate enhanced antibiotic resistance.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA. baumannii\u003c/em\u003e utilizes its T6SS to secrete effector proteins, killing competing bacteria and promoting horizontal gene transfer (HGT) via the release of extracellular DNA, thereby improving its ecological competitiveness [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In this study, AB\u003csup\u003eT6SS+\u003c/sup\u003e significantly reduced \u003cem\u003eE. coli\u003c/em\u003e TG1P populations when co-cultured, indicating enhanced competitive inhibition and host colonization ability. Similarly, Dong et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported that wild-type \u003cem\u003eA. baumanni\u003c/em\u003ei with functional T6SS effectively killed \u003cem\u003eE. coli\u003c/em\u003e JM109P and acquired its antimicrobial resistance plasmid. Repizo et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] confirmed T6SS activity in multiple strains, including ATCC 17978 and DSM30011. Additionally, \u003cem\u003eA. baumannii\u003c/em\u003e exhibits antifungal activity through nucleases like TafE and T6e1 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. T6SS activation is thus crucial for adaptation to nutrient-limited and highly competitive environments.\u003c/p\u003e \u003cp\u003eWhole-genome sequencing of four CR-hvAB strains revealed differences between ΔT6SS and intact-T6SS strains, particularly in the HigAB toxin-antitoxin system and RSF1010-like IncQ plasmids. The toxin-antitoxin system contributes to stress response, virulence, and tolerance, and promotes IncC plasmid stability in antibiotic-free environments, aiding bacterial survival [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The RSF1010-like IncQ plasmid has a broad host range and replicates stably across species [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Genomic analyses suggest that T6SS-deficient strains may adapt by upregulating alternative systems like toxin-antitoxin modules, while T6SS-intact strains utilize this system to acquire plasmids and resistance genes for competitive advantage.\u003c/p\u003e \u003cp\u003eAn upstream insertion sequence can modulate downstream gene expression either through its own promoter activity or by forming a hybrid promoter with adjacent sequences, thereby helping bacteria adapt to environmental changes. In AB26 and AB51, IS\u003cem\u003eAba13\u003c/em\u003e was inserted at the \u003cem\u003etssH\u003c/em\u003e locus: AB26 carried a truncated insertion with partial loss, while AB51 remained intact. AB41 had a 17 kbp deletion covering the entire T6SS cluster after IS\u003cem\u003eAba13\u003c/em\u003e. Adhesion to BEAS-2B cells ranked as: AB78 (intact T6SS, no insertion) \u0026gt; AB51 (intact T6SS with ISAba13) \u0026gt; AB26 (partial deletion) \u0026gt; AB41 (complete deletion). Pan et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] reported reduced adhesion in an hcp deletion mutant, and Wang et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] found that Δ\u003cem\u003evgrG\u003c/em\u003e showed impaired growth, adhesion, and virulence. Adams et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] identified IS\u003cem\u003eAba13\u003c/em\u003e in 22.4% of \u003cem\u003eA. baumannii\u003c/em\u003e genomes; insertions of IS\u003cem\u003eAJO2\u003c/em\u003e/IS\u003cem\u003eAba13\u003c/em\u003e in \u003cem\u003elpxA\u003c/em\u003e, \u003cem\u003elpxD\u003c/em\u003e, or \u003cem\u003epldA\u003c/em\u003e led to colistin dependence via altered membrane integrity and efflux expression [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. An intact T6SS enhances adhesion and virulence, while IS\u003cem\u003eAba13\u003c/em\u003e insertion may downregulate effector genes, suppressing T6SS activity and reducing pathogenicity and resistance.\u003c/p\u003e \u003cp\u003eIn conclusion, a high proportion of \u003cem\u003eA. baumannii\u003c/em\u003e bloodstream infections demonstrate multidrug or extensive drug resistance and evidence of clonal spread. Both resistance and pathogenicity are closely linked to the T6SS, whose activity may be downregulated by IS\u003cem\u003eAba13\u003c/em\u003e insertion, attenuating virulence and resistance profiles. Therefore, enhanced monitoring and infection control measures, particularly in ICUs, are urgently needed to limit its transmission. The T6SS represents a potential biomarker for assessing \u003cem\u003eA. baumannii\u003c/em\u003e resistance and pathogenic potential.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Due to experimental constraints, transformation experiments employed only kanamycin-sensitive strains, with a limited number of isolates. Certain analyses, including real-time single-molecule WGS and cell adhesion assays, were performed only on selected strains. Further mutant construction is required to clarify the precise role of IS\u003cem\u003eAba13\u003c/em\u003e in T6SS-mediated resistance and pathogenicity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMODS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultiple organ dysfunction syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePICC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperipherally inserted central venous catheter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ewhite blood cell\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNEUT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eneutrophil granulocyte.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics declarations\u003c/h2\u003e \u003cp\u003e The study was approved by the Clinical Research Medical Ethics Subcommittee of the Medical Ethics Committee of Xiangya Hospital, Central South University (Approval No. 202209541) and adhered to the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from the participant included in the study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the Natural Science Foundation of Hunan Province (No. 2022JJ70084, No. 2023JJ30900).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJun Li and Mengli Tang analyzed the data and wrote and edited the manuscript. Zhaojun Liu, Haolan Wang, and Yubing Xia carried out the experiments. Yongmei Hu, Haichen Wang and Fengjun Xia contributed to the methodology and data curation. Mingxiang Zou designed the project and revised the manuscript. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the doctors from the Department of Clinical Laboratory, Xiangya Hospital, for their assistance in specimen collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting this study's findings are openly available in the NCBI BioProject repository under BioProject accession number PRJNA1206144.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlfouzan, W., Dhar, R., Abdo, N. M., Alali, W. Q. \u0026amp; Rabaan, A. A. Epidemiology and Microbiological Profile of Common Healthcare Associated Infections among Patients in the Intensive Care Unit of a General Hospital in Kuwait: A Retrospective Observational Study. \u003cem\u003eJ. Epidemiol. 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Colistin Dependence in Extensively Drug-Resistant \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e Strain Is Associated with IS\u003cem\u003eAjo2\u003c/em\u003e and IS\u003cem\u003eAba13\u003c/em\u003e Insertions and Multiple Cellular Responses. \u003cem\u003eInt. J. Mol. Sci.\u003c/em\u003e \u003cb\u003e22\u003c/b\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijms22020576\u003c/span\u003e\u003cspan address=\"10.3390/ijms22020576\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acinetobacter baumannii, Type VI secretion system, Resistance, Pathogenicity, Insertion sequence","lastPublishedDoi":"10.21203/rs.3.rs-9192368/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9192368/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe Type VI secretion system (T6SS) is a multi-component transmembrane apparatus that is crucial for substance acquisition and pathogenicity of bacteria. In this study we investigated \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e, a causative agent of bacteremia, to explore the mechanisms of T6SS in drug resistance and pathogenicity by contrasting virulence, drug sensitivity, conjugation, transformation, competition, and cell adhesion capacities. A total of 136 non-repetitive \u003cem\u003eA. baumannii\u003c/em\u003e strains were collected, and 80.1% of patients received treatment in intensive care unit. Forty (29.4%) were classified as hypervirulent \u003cem\u003eA. baumannii\u003c/em\u003e (hvAB), which exhibited a higher prevalence of the virulence gene \u003cem\u003eabaI\u003c/em\u003e, a reduced capacity for biofilm formation, and a lower prevalence of the outer membrane protein gene \u003cem\u003ecarO\u003c/em\u003e. T6SS-positive strains exhibited enhanced antimicrobial resistance, elevated frequencies of resistance genes (\u003cem\u003ebla\u003c/em\u003e\u003csub\u003eOXA\u0026minus;23\u0026minus;like\u003c/sub\u003e, \u003cem\u003ebla\u003c/em\u003e\u003csub\u003eTEM\u003c/sub\u003e, \u003cem\u003eadeB\u003c/em\u003e, \u003cem\u003eadeR\u003c/em\u003e, \u003cem\u003eadeS\u003c/em\u003e) and the virulence gene \u003cem\u003ecsuE\u003c/em\u003e. Differences were observed between strains with T6SS deletion and those with an intact T6SS concerning the HigAB toxin-antitoxin system and the RSF1010-like IncQ plasmid. T6SS may down-regulate the expression of effector genes due to the insertion sequence IS\u003cem\u003eAba13\u003c/em\u003e. The critical role of the T6SS in the drug resistance and pathogenicity of \u003cem\u003eA. baumannii\u003c/em\u003e necessitates strengthened surveillance and the prompt implementation of effective measures.\u003c/p\u003e","manuscriptTitle":"The role of Type VI Secretion System in resistance and pathogenicity of Acinetobacter baumannii","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 09:09:31","doi":"10.21203/rs.3.rs-9192368/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T12:46:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T10:52:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T08:25:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256645446274807516241036105141075185147","date":"2026-04-13T04:13:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185019994538503515848370082694754723678","date":"2026-04-10T14:47:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12551682823144638766011141886765989406","date":"2026-04-02T14:53:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-31T14:26:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-26T12:56:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T11:39:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T11:38:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-03-22T15:24:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5f9d4f5b-a0cd-4bf3-81f1-dbab45b77e3a","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-29T12:46:20+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":65626690,"name":"Biological sciences/Microbiology"},{"id":65626691,"name":"Biological sciences/Molecular biology"}],"tags":[],"updatedAt":"2026-05-18T16:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 09:09:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9192368","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9192368","identity":"rs-9192368","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}