Genomic Characteristics and Risk Factor Analysis of Carbapenem-non-susceptible pseudomonas aeruginosa Causing Bacteremia in a Tertiary Hospital (2014-2023)

Genomic Characteristics and Risk Factor Analysis of Carbapenem-non-susceptible pseudomonas aeruginosa Causing Bacteremia in a Tertiary Hospital (2014-2023) | 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 Research Article Genomic Characteristics and Risk Factor Analysis of Carbapenem-non-susceptible pseudomonas aeruginosa Causing Bacteremia in a Tertiary Hospital (2014-2023) Junbin Zhai, Xiaoli Cao, Chang Liu, Jie Zheng, Yan Zhang, Shuo Gao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7307226/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Mar, 2026 Read the published version in BMC Microbiology → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Carbapenem-non-susceptible Pseudomonas aeruginosa (CnSPA) bloodstream infections (BSIs) are associated with high mortality and present significant clinical and public health challenges. This study aimed to investigate the genomic characteristics, resistance mechanisms, clinical features, and risk factors associated with CnSPA BSIs. Methods: A total of 52 consecutive, non-duplicate CnSPA isolates causing BSIs were collected from 2014 to 2023. Whole genome sequencing (WGS) was conducted to analyze antimicrobial resistance genes, sequence types (STs), serotypes, and mutations in carbapenem resistance-associated genes ( oprD , ampC , pbpA , pbpC ). Clinical data were collected to identify patient demographics, comorbidities, invasive procedures, and outcomes. Statistical analyses included logistic regression for risk factor identification and survival analysis for prognostic factors. Results: Among the 30 kinds of ARGs found, three carbapenemase encoding genes including bla KPC-2 (n = 1), bla VIM-2 (n = 1) and bla Pom-1 (n = 1) were identified. Genomic analysis revealed 36 distinct STs, with ST235, ST244, ST274, and ST357 being the most prevalent. Insertion sequences (ISs) were co-located with resistance genes in 96.2% of isolates, indicating a high potential for horizontal gene transfer. The serotypes analysis revealed a diverse distribution of O-antigen serotypes, with O11 (n = 15) being the most prevalent. oprD gene mutations were found in 92.3% of isolates. Mutations in ampC (88.5%) and pbpC (82.7%) contributed to resistance, but no pbpA mutations were detected. Clinically, the median patient age was 67 years, with male predominance (69.2%) and high mortality (38.5%). Logistic regression identified prolonged mechanical ventilation (≥ 7 days), History of carbapenem antibiotic exposure (≤ 90 days) and organ failure as independent risk factors for mortality, while prolonged indwelling catheterization (≥ 7 days) was an independent risk factor for polymicrobial infections. Conclusions: Our study showed that carbapenem resistance in CnSPA is predominantly driven by oprD inactivation and other gene mutations rather than carbapenemase production. The high genetic diversity among isolates emphasizes the need for robust genomic surveillance. Clinically, prolonged invasive procedures and critical illness contribute to adverse outcomes, underscoring the importance of infection control measures and timely management. These findings provide valuable insights into guiding antimicrobial stewardship and improving clinical outcomes for CnSPA BSI patients. Carbapenem-non-susceptible Pseudomonas aeruginosa bloodstream infections carbapenem resistance oprD mutations antimicrobial resistance whole genome sequencing risk factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Background Pseudomonas aeruginosa is a ubiquitous opportunistic pathogen responsible for a range of severe infections, particularly in immunocompromised individuals [ 1 ] . Among these infections, bacteremia caused by this pathogen remains a significant concern due to its high morbidity and mortality rates [ 2 ] . The increasing prevalence of carbapenem-non-susceptible P. aeruginosa (CnSPA) has further complicated treatment regimens, posing a critical challenge to healthcare systems globally [ 3 ] . Carbapenems are considered last-resort antibiotics for treating infections caused by multidrug-resistant Gram-negative bacteria [ 4 ] . However, the emergence of CnSPA underscores the need to better understand the genetic mechanisms driving resistance and the associated clinical risk factors [ 5 ] . Resistance in CnSPA is often attributed to the overexpression of efflux pumps, loss of porins, or the acquisition of carbapenemase genes, which can be disseminated via mobile genetic elements [ 6 , 7 ] . These genomic adaptations not only reduce treatment efficacy but also enhance the pathogen's fitness and adaptability. Epidemiological studies have highlighted the importance of risk factor identification in preventing and managing CnSPA infections. Factors such as prolonged hospital stays, prior exposure to antibiotics, invasive procedures, and comorbidities are frequently linked to these infections [ 8 ] . Prior carbapenem treatment, in particular, has been suggested to exert selective pressure that promotes the emergence and spread of resistant strains; however, comprehensive analyses specifically focusing on this factor remain limited, especially in the context of bloodstream infections (BSIs). This study aims to bridge this gap by investigating the genomic features and risk factors of CnSPA strains isolated from BSIs in a tertiary hospital over a ten-year period (2014–2023). By combining whole-genome sequencing (WGS) with clinical data analysis, including the evaluation of prior carbapenem exposure, we seek to identify key genetic determinants of resistance and delineate patient-related risk factors contributing to the spread of CnSPA. These findings will provide valuable insights for infection control strategies and antibiotic stewardship programs. 2. Materials and methods 2.1 Bacterial strains A total of 52 consecutive and non-duplicate bloodstream isolates of CnSPA from our hospital between 2014 and 2023 were collected. Blood cultures were processed using the BD BACTEC™ FX system (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) following standard clinical microbiology protocols. Positive cultures were subcultured onto blood agar (Oxoid, UK) and incubated at 37°C for 18–24 hours under aerobic conditions. Colony morphology and Gram staining were assessed for preliminary identification, while species confirmation was performed using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, bioMérieux, France). Antimicrobial susceptibility testing was conducted using the microbroth dilution method, and interpretation of results followed the Clinical and Laboratory Standards Institute (CLSI), Performance Standards for Antimicrobial Susceptibility Testing, M100, 35th Edition. Escherichia coli ATCC25922 was used as quality control. 2.2 Genomic extraction, whole genome sequencing and Genome Assembly Genomic DNA was extracted from overnight cultures of each P. aeruginosa isolate grown on Luria-Bertani (LB) agar at 37°C for 18 hours using the TianGen Bacterial Genomic DNA Kit (Tiangen Biochemical Technology Co., Ltd., China) following the manufacturer’s protocol. DNA purity and concentration were assessed using a NanoDrop 2000 spectrophotometer and Qubit Fluorometer (Thermo Fisher Scientific, USA), while DNA integrity was evaluated by 1% agarose gel electrophoresis. For whole genome sequencing, DNA libraries were prepared using the NEBNext Ultra II DNA Library Prep Kit for Illumina and sequenced on an Illumina NovaSeq 6000 platform (Illumina, USA) with paired-end 150 bp reads, ensuring a minimum sequencing depth of 30× coverage per genome. Raw sequencing reads underwent quality assessment with FastQC (v0.11.9) and trimming using Trimmomatic (v0.39). De novo genome assembly was performed using SPAdes (v3.15.4) with default parameters, and contigs were filtered for a minimum length of 500 bp. Assembly quality was assessed using QUAST (v5.0.2), and the final assembled genomes were submitted to GenBank. 2.3 Identification of Antibiotic Resistance Genes, Sequence Types, and Mobile Genetic Elements Antibiotic resistance genes (ARGs) were identified using ResFinder 4.1 ( https://cge.food.dtu.dk/services/ResFinder/ ) with a threshold of ≥ 90% identity and ≥ 60% coverage. Sequence types (STs) were determined using MLST 2.0 (v2.0.9, https://cge.food.dtu.dk/services/MLST/ ), with allele profiles retrieved from PubMLST.org. Mobile genetic elements (MGEs) were identified using Mobile Element Finder (v1.0.3, Database v1.0.2). 2.4 Whole-Genome Sequencing-Based Serotyping of P. aeruginosa Whole-genome sequences of the isolates were analyzed using the O-specific antigen (OSA) prediction method described by Thrane et al. [ 9 ] . The Pseudomonas aeruginosa serotyper (PAst) tool was employed to assign serotypes based on genomic data. WGS data were screened for O-antigen biosynthesis gene clusters, and serotype assignment was conducted based on gene content and sequence homology. Additionally, serotype-specific gene markers were identified using a BLAST-based approach with reference sequences from known O-serotypes. 2.5 Mutation analysis of carbapenem resistance related genes including oprD, ampC, pbpA and pbpC Genes associated with carbapenem resistance ( oprD , ampC , pbpA , and pbpC ) were extracted from assembled genomes using a custom Python script and aligned with the reference strain P. aeruginosa PAO1 (NC_002516.2) using MUSCLE (v3.8.1551) [ 10 ] . Single nucleotide polymorphisms (SNPs), insertions, deletions, and frameshift mutations were identified using Snippy (v4.6.0), while their functional effects were predicted using SIFT (Sorting Intolerant from Tolerant) and PolyPhen-2 (Polymorphism Phenotyping v2) [ 11 , 12 ] . 2.6 Clinical data collection Clinical data of patients with confirmed CnSPA bloodstream infections (BSIs) were obtained from electronic medical records between 2014 and 2023. Inclusion criteria included a positive blood culture for CnSPA and availability of complete clinical data, while patients with incomplete medical records were excluded. The analyzed clinical variables included demographics (age, gender), comorbidities (hypertension, diabetes, malignancy, renal failure, open trauma), prior antibiotic use (carbapenems), presence of invasive devices (central venous catheters, mechanical ventilation), Intensive care unit (ICU) admission and recent surgeries, as well as length of hospital stay and clinical outcomes (mortality, infection resolution). Ethical approval for this study was obtained from the Ethics Committee of Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University (Approval No. 2023 − 390) and this study was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective and anonymized nature of the study. 2.7 Definitions Primary BSI: Bloodstream infection with no identifiable infection source other than the bloodstream. Secondary BSI [ 13 ] : Bloodstream infection resulting from an infection at another site. Mixed Infections: CnSPA detected alongside other bacterial pathogens in the same blood culture or concurrent infections at different sites. 2.8 Statistical Analysis For Risk Factor Analysis: Categorical variables were compared using chi-square tests or Fisher’s exact tests, and continuous variables were compared using t-tests or Mann-Whitney U tests as appropriate. Variables with p < 0.05 in univariate analysis were included in a multivariate logistic regression model to identify independent risk factors for CnSPA BSIs. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. For Prognostic Factors for CnSPA BSIs: Survival analysis was conducted using Kaplan-Meier curves to estimate survival probabilities, and the log-rank test was used to compare survival distributions. Cox proportional hazards regression was performed to identify independent prognostic factors for mortality in patients with CRPA BSIs. Hazard ratios (HRs) and 95% CIs were reported. 3. Results 3.1 The resistant rates of 52 CnSPA isolates Resistance rates were highest against imipenem, with 98.1% of the strains resistant, followed by ciprofloxacin at 63.5%, and levofloxacin at 50.0%. Moderate resistance was observed against other antibiotics, including ticarcillin/clavulanic Acid (57.7%), Tazobactam/Piperacillin (40.4%), cefoperazone/sulbactam (38.5%), and meropenem (36.5%). Resistance to beta-lactams was also notable, with 23.1% of strains resistant to ceftazidime and 13.5% resistant to cefepime. Aminoglycosides showed varying resistance, with 13.5% of strains resistant to both amikacin and tobramycin. All the strains were susceptible to colistin (The resistant profiles were shown in Table 1 and minimum inhibitory concentrations of 52 P. aeruginosa are detailed in Table S1 ). Table 1 The sequence typing, serotype, resistance profile, and resistance gene of the 52 Pseudomonas aeruginosa isolates Strain Sequence typing Serotype Resistance profile b Resistance gene 2745 ST357 O11 TCC-CSP-IPM-MEM-LVX fosA, aph(3')-IIb, blaPAO, blaOXA-50, catB7 3077 ST244 O5 IPM fosA, catB7, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb 3206 ST357 O11 TCC-TZP-CAZ-CSP-IPM-MEM-LVX fosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50 3567 Un a O1 TCC-TZP-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX fosA, aadA1, qacE, blaOXA-14, ant(2'')-Ia, sul1, blaPAO, aph(3')-IIb , blaOXA-488, catB7, crpP 4087 ST235 O11 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-TOB-CIP-LVX aadA1, blaOXA-14, ant(2')-Ia, qacE,sul1, ant(2')-Ia, blaPAO, aph (3')-IIb, crpP, blaOXA-488, catB7 4591 ST348 O5 TCC-TZP-CSP-IPM-MEM-CIP-LVX fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7 4996 ST235 O11 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX fosA, qacE, blaPAO, aph(3')-IIb, sul1, blaGES-1, aac(6')-Ib3, aph (3')-XV, aac(6')-Ib-cr, blaOXA-488, tet(G), catB7 5241 ST4003 O6 IPM-MEM fosA, blaPAO, aph(3')-IIb, blaOXA-396, catB7 5454 Un a O5 IPM-CIP-LVX fosA, blaOXA-494, blaPAO, aph(3')-IIb, catB7 5563 ST882 O6 IPM fosA, crpP, blaPAO, aph(3')-IIb, blaOXA-486, catB7 6012 ST244 O2 IPM-CIP-LVX fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP 6650 ST871 O6 TCC-IPM-MEM fosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7 6868 ST708 O2 IPM fosA, blaOXA-50, blaPAO, aph(3')-IIb, catB7, crpP 7106 ST1182 O6 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX fosA, blaTEM-1B, aac(3)-IId, qacE, sul1, rmtB, blaPAO, aph(3') -IIb, catB7, aadA13, cmlA1, aac(6')-IIa, crpP, aph(3'')-Ib, aph(6)-Id , blaOXA-246, blaOXA-395 7166 ST245 O2 TCC-IPM-MEM–CIP-LVX fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP 7318 ST390 O6 IPM fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP 7339 ST357 O11 IPM fosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50 7409 ST606 O13 IPM-LVX fosA, crpP, blaPAO, aph(3')-IIb, blaOXA-488, catB7 8681 ST1228 O1 IPM-MEM fosA, catB7, blaPAO, aph(3')-IIb, crpP 9002 ST316 O11 IPM blaOXA-395, aph(3')-IIb, blaPAO, fosA, catB7 9137 ST1971 O11 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX fosA, blaTEM-1B, rmtB, aac(3)-IId, blaPAO, aph(3')-IIb, blaOXA -246, aac(6')-IIa, aadA13, blaOXA-395, blaPER-1, dfrA1, aac(6') -Ib-cr, aac(6')-Ib3, aadA2b, cmlA1, tet(C), aph(6)-Id, aph(3'')-Ib, sul1, qacE, aph(3')-Ia, catB7 9524 ST274 O3 TCC-CSP-IPM-MEM-CIP-LVX fosA, aph(3')-IIb, blaPAO, catB7, blaOXA-486 9615 ST532 O11 TCC-IPM-MEM fosA, aph(3')-IIb, blaPAO, blaOXA-395, catB7 10041 ST508 O3 TCC-TZP-CSP-IPM-MEM-LVX fosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7 10291 ST274 O3 TCC-IPM-MEM fosA, aph(3')-IIb, blaPAO, catB7, blaOXA-486 11381 ST3382 O11 IPM fosA, blaPAO, aph(3')-IIb, blaOXA-488, catB7 11638 ST2554 O3 IPM-CIP-LVX fosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7 11749 ST463 O4 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX fosA, blaOXA-486, blaCARB-2, blaOXA-246, dfrA27, ARR-3, cmlA1 , ant(2'')-Ia, crpP, blaPAO, aph(3')-IIb, crpP, qacE, sul1, aadA24 , cmlA1, aac(6')-II, blaKPC-2, catB7, aac(6')-IIa 12218 ST3960 O11 IPM-MEM-TOB-CIP-LVX fosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486 12253 ST313 O1 TCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB fosA, blaVIM-2, aac(6')-Ib-cr, aac(6')-Ib3, blaOXA-10, aadA2b, crpP , blaPAO, aph(3')-IIb, blaOXA-488, catB7 13101 ST379 O6 TCC-TZP-IPM-MEM fosA, catB7, blaOXA-494, blaOXA-50, blaOXA-396, blaPAO, aph(3') -IIb 13576 ST260 O6 TCC-TZP-CAZ-CSP-IPM-MEM-LVX blaPAO, aph(3')-IIb, catB7, crpP, blaOXA-494, blaOXA-50, blaOXA -396 13910 ST1971 O11 TCC-IPM-MEM-CIP-LVX fosA, tet(C), blaPAO, aph(3')-IIb, blaOXA-395, catB7 14400 ST234 O4 TCC-IPM-MEM-CIP-LVX fosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7, crpP 14564 ST238 O1 TCC-TZP-CAZ-CSP-IPM-MEM-CIP-LVX fosA, aph(3')-IIb, blaPAO, blaOXA-395, catB7 14700 ST1076 O11 IPM fosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7, crpP 14760 ST242 O1 IPM fosA, catB7, blaOXA-50, blaPAO, aph(3')-IIb 15145 ST1974 O7 TZP-IPM-MEM fosA, catB7, blaPAO, aph(3')-IIb, blaOXA-50 15232 ST235 O11 IPM fosA, qacE, blaPAO, aph(3')-IIb, sul1, blaOXA-488, aadA6, crpP , catB7 15508 Un a O1 TZP-IPM-MEM fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7 16093 ST281 O6 TCC-TZP-CAZ-CSP-IPM-MEM-CIP-LVX fosA, catB7, blaOXA-486, blaPAO, aph(3')-IIb 16194 ST3580 O5 TCC-TZP-CAZ-CSP-IPM-MEM fosA, aph(3')-IIb, blaPAO, blaOXA-486 16359 ST494 O3 TCC-IPM-MEM-LVX fosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486, crpP 17448 ST494 O3 TCC-TZP-CSP-IPM(I c ) fosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486, crpP 17767 ST274 O3 IPM fosA, blaOXA-486, blaPAO, aph(3')-IIb, catB7 17774 ST1480 O1 IPM fosA, catB7, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb 17809 ST699 O2 IPM fosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50 18612 ST606 O13 TCC-TZP-CSP-IPM-MEM-LVX fosA, catB7, aph(3')-IIb, blaPAO, blaOXA-488 18985 Un a O11 TCC-TZP-IPM-MEM fosA, blaOXA-50, blaPAO, aph(3')-IIb, catB7 19199 Un a O11 TCC-CSP-IPM-MEM fosA, catB7, blaOXA-50, blaPAO, aph(3')-IIb, crpP 19686 ST277 O5 TCC-TZP-CAZ-CSP-IPM-MEM-AMK-TOB-CIP-LVX fosA, dfrA22, cmlA1, blaOXA-246, aac(6')-IIa, aph(3')-IIb, blaPAO , aac(6')-II, aadA24, ant(2'')-Ia, cmlA1, msr(E), mph(E), blaOXA-396 , blaOXA-494, ARR-2, sul1, qacE, crpP, qnrVC1, dfrA27, catB7 19733 ST244 O5 TCC-IPM-MEM-TOB-CIP-LVX fosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP , aph(3'')-Ib, aph(6)-Id, aac(6')-IIa a Unknown b TCC, Ticarcillin-clavulanate; TZP, piperacillin-tazobactam; CAZ, ceftazidime; CSP, Cefoperazone-Sulbactam; FEP, cefepime; IMP, imipenem; MEM, meropenem; AMK, amikacin; TOB, tobramycin; CIP, Ciprofloxacin; LVX, levofloxacin; c Intermediate 3.2 Few carbapenemase encoding Genes were found in CnSPA strains Totally, 30 kinds of ARGs were found with bla PAO (n = 85), bla OXA (n = 71), aph(3') (n = 58), catB7 (n = 51), and fosA (n = 51) being the most predominant ones (Fig. 1 ). In detail, among the 9 β-lactamase, three carbapenemase encoding genes including bla KPC-2 (n = 1), bla VIM-2 (n = 1) and bla Pom-1 (n = 1), bla OXA owned the most variants including bla OXA-10 (n = 1), bla OXA-14 (n = 2), bla OXA-246 (n = 4), bla OXA-395 (n = 7), bla OXA-396 (n = 12), bla OXA-486 (n = 14), bla OXA-488 (n = 8), bla OXA-494 (n = 12) and bla OXA-50 (n = 11). bla GES-1 (n = 1), bla CARB-2 (n = 1), bla PER-1 (n = 1) and bla TEM-1B (n = 2) (Table 1 ). 3.3 Wide distribution of resistance genes and insertion sequences in the same contig Insertional sequences (ISs) are a class of transposons capable of encoding enzymes required for transposition, with short reverse terminal repeats at both ends. During transposition, the insertion sequence copies the target sequence and forms two short forward repeats on either side of the transposon. In this study, 50 of 52 Pseudomonas aeruginosa strains showed that the resistance gene was located on the same contig as the insertion sequence, which significantly increases the possibility of resistance gene transfer and suggests that the insertion sequence is a key mobile element mediating resistance gene transfer (Fig. 2 ). Additionally, five strains were found to contain six transposons. Among them, Tn5563 was identified in three strains, Tn5501 was found in one strain, and Tn4371 and Tn6082 were detected in two other strains, respectively. Furthermore, Tn5501 and Tn5563 were present in a single strain. 3.4 Diverse sequence types suggest the genetic diversity of CnSPA Totally, 36 distinct STs were identified with ST235 (n = 3), ST244 (n = 3), ST274 (n = 3) and ST357 (n = 3) were the most prevalent ones followed by ST1971 (n = 2), ST606 (n = 2), and ST494 (n = 2). Other 29 STs were single. In addition, the ST type of 5 strains has not yet been determined (Table 1 ). 3.5 Serotypes of 52 CnSPA Isolates The serotyping analysis of 52 CnSPA isolates revealed a diverse distribution of O-antigen serotypes. Among these, O11 was the most prevalent, accounting for 15 isolates, followed by O6 (n = 8), O1 (n = 7), and O3 (n = 7). Other detected serotypes exhibited varying degrees of prevalence (Table 1 ). 3.6 Mutations may be the primary mechanism conferring non-susceptibility to carbapenem Among the 52 CnSPA isolates, no mutations were detected in the oprD gene of three isolates, while one isolate exhibited complete nonsense mutations in the oprD gene. The remaining 48 isolates showed varying degrees of amino acid changes caused by oprD gene mutations (Fig. 3 ). Additionally, mutations in the ampC gene led to amino acid alterations in 46 isolates (Fig. 4 ), and mutations in the pbpC gene caused amino acid changes in 43 isolates (Fig. 5 ). No mutations were detected in the pbpA gene among the 52 CnSPA isolates. 3.7 Clinical features of 52 patients with CnSPA Among the 52 patients included in the study, the highest numbers of cases occurred in 2017 and 2020, with seven cases each. The patient's ages ranged from 30 to 103 years, with a median age of 67 years. Male patients accounted for 69.2% (36 cases), with most being admitted to the intensive care unit (21.2%) or the geriatric department (17.3%). A majority of patients (92.3%, 48 cases) had hospital stays exceeding 10 days, and the overall prognosis was poor, with 38.5% (20 cases) dying during hospitalization. Comorbidities were common, as 76.9% (40 cases) of the patients had three or more underlying conditions, with hypertension being the most frequent (60%), followed by organ failure (45%), malignancy (37.5%), diabetes (30%), and open trauma (22.5%). Among the 32 patients with secondary bloodstream infections, over half (53.1%) originated from the lungs, while other infection sources included the urinary tract (12.5%), abdominal cavity (12.5%), biliary tract (9.4%), skin (9.4%), and catheters (3.1%). More than 30 patients underwent invasive procedures lasting over seven days, with intravenous catheterization being the most common (59.6%, 31 cases). 3.8 Risk factors for Mortality and Co-Infection in CnSPA-BSI Patients: A Logistic Regression Analysis Logistic regression analysis showed that history of carbapenem antibiotic exposure (≤ 90 days), organ failure, and mechanical ventilation (≥ 7 days) were independent risk factors for death in CnSPA-BSI patients (Table 2 ). Meanwhile, an indwelling catheter (≥ 7 days) was identified as an independent risk factor for bloodstream infection with CnSPA combined with other pathogens (Table 3 ). No independent risk factors for secondary CnSPA bloodstream infection were found in this study (Table 4 ). Table 2 Univariate and multivariate analysis of prognostic risk factors in the death and survival groups of Pseudomonas aeruginosa bloodstream infection variate Death group (n = 20) Survival group (n = 32) Test single factor analysis multiple-factor analysis x 2 /t value P value OR value (95% CI) P value OR value (95% CI) P value general information gender (male) (%) 15 (75.0%) 21 (65.6%) 0.508 0.476 age 65.7 ± 14.6 70.3 ± 17.7 0.963 0.340 Check-in department (ICU) (%) 12 (60.00%) 13 (40.63%) 1.851 0.174 Length of stay 40.5 (23.0, 55.0) 26 (17.0, 38.75) -1.769 0.077 History of carbapenem antibiotic exposure (≤ 90 days) 17 (85.00%) 17 (53.13%) 5.525 0.019 3.975 (0.895 ~ 17.643) 0.07 5.000 (1.221 ~ 20.483) 0.025 underlying disease high blood pressure (%) 8 (40.0%) 16 (50%) 0.495 0.482 diabetes (%) 4 (20%) 8 (25%) 0.173 0.677 malignant tumor (%) 9 (45.0%) 6 (18.75%) 4.132 0.042 3.034 (0.578 ~ 15.930) 0.19 open wound (%) 7 (35.0%) 2 (6.25%) 7.108 0.008 8.078 (1.076 ~ 60.627) 0.042 5.816 (0.904 ~ 37.395) 0.064 organ failure (%) 13 (65.0%) 5 (15.625%) 13.26 0.0003 14.888 (2.834 ~ 78.220) 0.001 14.077 (2.852 ~ 69.479) 0.001 Have three or more underlying diseases (%) 15 (75.0%) 25 (78.125%) 0.068 0.795 invasive procedure Surgery (%) 12 (60.0%) 18 (56.25%) 0.071 0.790 Intravenous catheterization (≥ 7 days) (%) 14 (70%) 17 (53.125%) 1.456 0.228 mechanical ventilation (≥ 7 days) (%) 14 (70.0%) 10 (31.25%) 7.436 0.006 4.122 (0.845 ~ 20.097) 0.08 5.133 (1.118 ~ 23.571) 0.035 indwelling catheter (≥ 7 days) (%) 13 (65%) 17 (53.25%) 0.711 0.399 Table 3 Univariate and multivariate analysis of prognostic risk factors for blood flow infection with Pseudomonas aeruginosa and other pathogens variate Pseudomonas aeruginosa with other pathogens bloodstream infection (n = 22) Simple pseudomonas aeruginosa bloodstream infection (n = 30) Test single factor analysis multiple-factor analysis x 2 /t value P value OR value (95% CI) P value OR value (95% CI) P value general information gender (male) (%) 15 (68.2%) 21 (70%) 0.020 0.888 age 72.3 ± 16.7 65.7 ± 16.1 1.714 0.093 Check-in department (ICU) (%) 13 (59.1%) 12 (40%) 1.853 0.173 Length of stay 34.5 (21.0, 48.75) 25.0 (17.0, 44.5) -1.242 0.214 History of carbapenem antibiotic exposure (≤ 90 days) 16 (47.06%) 18 (52.94%) 0.908 0.341 underlying disease high blood pressure (%) 13 (59.1%) 11 (36.7%) 2.568 0.109 diabetes (%) 5 (22.73) 7 (23.33%) 0.003 0.959 malignant tumor (%) 4 (18.18%) 11 (36.67%) 4.356 0.037 0.775 (0.163 ~ 3.676) 0.748 open wound (%) 3 (13.64) 6 (20%) 0.359 0.549 organ failure (%) 8 (36.36%) 10 (33.33%) 0.052 0.821 Have three or more underlying diseases (%) 19 (86.36%) 21 (70%) 1.915 0.167 invasive procedure Surgery (%) 16 (72.73%) 14 (46.67%) 0.069 0.793 Intravenous catheterization (≥ 7 days) (%) 17 (77.27%) 14 (46.67%) 5.992 0.014 1.566 (0.354 ~ 6.927) 0.554 mechanical ventilation (≥ 7 days) (%) 13 (59.09%) 11 (36.67%) 2.568 0.109 indwelling catheter (≥ 7 days) (%) 19 (86.36%) 11 (36.67%) 12.84 0.0003 8.422 (1.757 ~ 40.382) 0.008 10.939 (2.628 ~ 45.539) 0.001 Table 4 Univariate and multivariate analysis of prognostic risk factors for primary and secondary bloodstream infections with Pseudomonas aeruginosa variate Primary bloodstream infection group (n = 20) Secondary bloodstream infection group (n = 32) Test x 2 /t value P value general information gender (male) (%) 15 (75.0%) 21 (65.6%) 0.508 0.476 age 67.8 ± 15.8 69.0 ± 17.3 0.256 0.799 Check-in department (ICU) (%) 8 (40%) 17 (53.125%) 0.271 0.602 Length of stay 27.0 (17.25, 42.0) 30.0 (20.25, 55.0) -0.828 0.408 History of carbapenem antibiotic exposure (≤ 90 days) 10 (50%) 24 (70.59%) 3.399 0.065 underlying disease high blood pressure (%) 6 (30%) 18 (56.25%) 2.684 0.101 diabetes (%) 3 (15.0%) 9 (28.125%) 1.194 0.274 malignant tumor (%) 8 (40%) 7 (21.875%) 2.166 0.141 open wound (%) 1 (5%) 8 (25%) 2.576 0.109 organ failure (%) 7 (35%) 11 (34.375%) 0.002 0.963 Have three or more underlying diseases (%) 16 (80%) 24(75%) 0.048 0.827 invasive procedure Surgery (%) 14 (70%) 16 (50%) 2.017 0.156 Intravenous catheterization (≥ 7 days) (%) 12 (60%) 19 (59.375%) 0.087 0.768 mechanical ventilation (≥ 7 days) (%) 7 (35%) 17 (53.125%) 1.627 0.202 indwelling catheter (≥ 7 days) (%) 10 (50%) 20 (62.5%) 0.788 0.374 4. Discussion This study insights into the genomic characteristics, resistance mechanisms, and clinical features of CnSPA strains, highlighting key findings and implications for clinical management and infection control strategies. The findings of this study reveal a concerning level of resistance among CnSPA isolates, with widespread β-lactam, fluoroquinolone, and aminoglycoside resistance, as well as the presence of MDR and XDR phenotypes. These resistance trends highlight the urgent need for innovative treatment strategies, rigorous infection control, and global surveillance efforts to curb the spread of CnSPA. Correspondingly, the identification of multiple resistance genes may provide explanation for the resistance. Of note, only three carbapenemase-encoding genes were identified, each in a single isolate. This supports prior findings that carbapenemase production is not the predominant mechanism of carbapenem resistance in P. aeruginosa [ 14 , 15 ] . In addition to the carbapenemase genes, other β-lactamase genes were also present but in very low numbers, further emphasizing that β-lactamase production is not the dominant mechanism in this cohort. Furthermore, our study showed that the bla OXA family exhibited the greatest diversity. The widespread presence and diversity of bla OXA variants may reflect the evolutionary adaptations of P. aeruginosa in response to selective pressure from β-lactam antibiotics. Of note, most bla OXA genes are not directly associated with carbapenem resistance, some variants, such as bla OXA-50, have been linked to intrinsic resistance in P. aeruginosa [ 16 ] . Thus, the limited presence of carbapenemase-encoding genes in CnSPA indicate that non-carbapenemase-mediated resistance mechanisms, such as efflux pumps, porin mutations, and β-lactamase hyperproduction may confer resistance to carbapenems. The identification of 36 distinct STs among the 52 CnSPA isolates underscores the high genetic diversity of these strains. The most prevalent STs-ST235, ST244, ST274, and ST357 are globally recognized MDR clones frequently implicated in hospital outbreaks [ 17 ] . Among them, ST235, in particular, has been reported worldwide, often carrying bla VIM and bla KPC [ 2 ] . ST244 is another well-documented high-risk clone associated with nosocomial infections and diverse resistance mechanisms [ 18 ] . Beyond these dominant STs, our study identified 29 unique STs, each represented by a single isolate, along with five undetermined STs. These rare STs may represent local or emerging clones with limited dissemination. Their presence highlights the continuous genetic evolution of P. aeruginosa , driven by mutation accumulation, recombination, and horizontal gene transfer (HGT) [ 19 ] . Comparing our findings with prior epidemiological studies, ST235 and ST244 have been widely reported in China, Europe, and North America [ 17 ] , while ST1971, ST606, and ST494 have been detected sporadically, suggesting a possible regional expansion of these clones [ 18 ] . The high frequency of unique STs may indicate local evolution within our hospital setting, possibly due to antibiotic selection pressure and adaptive responses to environmental conditions. Further WGS-based phylogenetic analyses will be necessary to track their transmission routes and evolutionary dynamics. ISs are key genetic elements promoting HGT, enabling the movement of resistance genes between plasmids, transposons, and chromosomes [ 20 , 21 ] . Our study found that 50 of 52 CnSPA isolates harbored resistance genes on the same contig as IS elements, indicating that ISs may facilitate rapid resistance gene transfer within P. aeruginosa populations. Previous studies have shown that IS-mediated recombination plays a significant role in the dissemination of carbapenemase genes such as bla VIM, bla IMP, and bla NDM [ 22 ] . In our isolates, the strong association of IS elements with β-lactamase genes ( bla OXA, bla PAO, bla CARB) suggests that transposition events contribute to increased resistance gene mobility. Additionally, IS elements can activate adjacent resistance genes by introducing strong promoters, leading to increased gene expression and enhanced resistance phenotypes [ 23 ] . From an epidemiological perspective, the widespread presence of IS-associated ARGs raises concerns about cross-species gene transfer in hospital settings. ICU environments, where high antibiotic use and bacterial co-colonization are common, provide ideal conditions for such genetic exchanges [ 24 ] . The ability of P. aeruginosa to act as a resistance gene reservoir underscores the urgent need for enhanced infection control measures, including genomic surveillance to monitor IS-mediated resistance transmission. Among the identified serotypes, O11 was the most frequently detected, which is consistent with previous studies indicating that O11 is one of the most predominant serotypes in hospital-acquired P. aeruginosa infections [ 25 ] . This serotype is often associated with MDR, biofilm formation, and chronic infections, making it a major concern in nosocomial settings [ 25 ] . Similarly, O6, O1, and O3 serotypes were also frequently identified, reflecting their significant presence in clinical infections [ 26 ] . Previous reports have suggested that O6 is often linked to antibiotic resistance and increased virulence, while O1 and O3 have been associated with both acute and chronic infections [ 27 ] . The relatively high prevalence of these serotypes suggests potential clonal expansion and highlights the need for continuous monitoring to track their epidemiological trends. The detection of multiple O-serotypes in this study suggests that CnSPA exhibits a high degree of serotypic variability, which may contribute to immune evasion, antimicrobial resistance, and adaptation to different host environments. This diversity could be driven by HGT, genetic recombination, or selective pressure from antibiotic use and host immune responses. The analysis of mutations in the oprD , ampC , pbpC , and pbpA genes highlights their distinct contributions to carbapenem resistance in P. aeruginosa . The widespread presence of oprD mutations in 48 of 52 isolates, including frequent alterations such as E230K, S240T, N262T, E202Q, and I210A, suggests that OprD porin loss or functional impairment is the primary driver of carbapenem non-susceptibility [ 28 ] . These findings align with prior research by Nazari et al. and and Fazeli et al [ 29 ] . which reported significant oprD downregulation in imipenem-resistant P. aeruginosa isolates. Mutations in ampC (46 isolates) and pbpC (43 isolates) were also prevalent, with the ampC T105A substitution being the most common. This finding is consistent with prior studies showing that ampC overexpression contributes to cephalosporin resistance and enhances P. aeruginosa survival under antibiotic stress [ 30 ] . Meanwhile, pbpC mutations such as A104P may modify penicillin-binding protein function, further contributing to β-lactam resistance [ 31 ] . The lack of significant mutations in pbpA suggests that it plays a limited role in resistance within this cohort. Overall, these findings reinforce the multifactorial nature of carbapenem resistance in P. aeruginosa , where porin loss and β-lactamase overproduction work synergistically to reduce antibiotic efficacy. In addition, our study predominantly consisted of elderly patients, reflecting the vulnerability of older adults to P. aeruginosa infections due to age-related immune decline, multiple comorbidities, and frequent hospital exposures [ 32 ] . The predominance of a male was observed, potentially linked to biological or healthcare utilization differences. Most patients experienced extended hospital stays exceeding 10 days, indicating that prolonged hospitalization is both a risk factor for and a consequence of CnSPA infections. Admission to the ICU underscores the association of these infections with critically ill and vulnerable populations [ 33 ] . The overall poor prognosis with a high mortality rate during hospitalization highlights the clinical severity of CnSPA infections, which may be often compounded by delays in effective treatment due to MDR. The common comorbidities likely increased susceptibility to infection. The high frequency of secondary BSI highlighted the opportunistic nature of CnSPA in exploiting multiple entry points [ 34 ] . The common invasive procedures lasting over seven days emphasized medical devices as significant risk factors and reservoirs for nosocomial infections [ 35 ] . Furthermore, the independent risk factor identified in our study align with previous study. As we know that mechanical ventilation has been widely reported as a major risk factor for P. aeruginosa BSIs due to its association with ventilator-associated pneumonia and nosocomial sepsis [ 36 ] . Shi Q et al. and Yuan Q et al. also identified prolonged mechanical ventilation as a key predictor of mortality in MDR P. aeruginosa BSI patients [ 34 , 37 ] . The underlying mechanisms include immune suppression from critical illness, microbial aspiration, and biofilm formation in ventilator circuits, all of which increase infection risk. Similarly, organ failure has been consistently linked to poor outcomes in bacterial sepsis. Dong L et al. demonstrated that sepsis-induced multi-organ dysfunction significantly increases mortality in P. aeruginosa infections [ 38 ] . Importantly, our study further identified that prior exposure to carbapenem antibiotics (within 90 days) was an independent risk factor for mortality in patients with CnSPA BSIs. This finding directly supports the hypothesis raised in our introduction and corroborates prior studies indicating that previous carbapenem use exerts strong selective pressure, promoting the proliferation of resistant P. aeruginosa strains [ 39 , 40 ] . In clinical practice, prior exposure to broad-spectrum antibiotics like carbapenems not only disrupts the normal flora but also facilitates the selection and expansion of resistant clones, thereby increasing the likelihood of adverse clinical outcomes [ 32 , 41 ] . The inclusion of this variable in our multivariate analysis reinforces its significance and provides actionable evidence for antimicrobial stewardship programs aimed at minimizing unnecessary carbapenem use to reduce mortality risk. The association of long-term catheterization with polymicrobial BSIs supports the notion that indwelling devices serve as bacterial reservoirs, facilitating biofilm formation and persistent colonization. This finding aligns with Buetti N et al. [ 42 ] , who found that prolonged catheterization significantly increases the risk of catheterization related BSIs, particularly in ICU patients. Interestingly, our study did not identify independent risk factors for secondary CnSPA BSIs, which contrasts with previous reports suggesting that prior colonization, immunosuppression, and prolonged antibiotic exposure may play key roles [ 37 ] . This discrepancy may be due to differences in study design, sample size, or patient demographics, necessitating larger multi-center investigations to further explore secondary infection risk factors. Given these findings, early identification of high-risk patients and aggressive critical care management are crucial. Implementing ventilator stewardship programs, preventing and managing organ failure at an early stage, and adopting strict catheter management protocols can significantly reduce infection risks and improve patient outcomes. This study has several limitations that should be acknowledged. First, it is a single-center study with a relatively small sample size, which may limit the generalizability of the findings to other healthcare settings or regions. Second, molecular analyses were focused on selected ARGs and mutations; thus, other genetic factors contributing to resistance such as overexpressed efflux pumps have been overlooked. 5. Conclusion This study elucidates the genomic diversity, resistance mechanisms, and clinical risk factors associated with CnSPA BSIs. We found that carbapenem resistance in P. aeruginosa is driven primarily by oprD , ampC , and pbpC mutations rather than carbapenemase production. The high genetic diversity of STs, along with the widespread presence of IS elements facilitating HGT, underscores the urgent need for genomic surveillance. Furthermore, the identification of mechanical ventilation, prior carbapenem exposure (≤ 90 days) and organ failure as mortality risk factors reinforces the importance of early clinical intervention to improve patient outcomes. Targeted efforts to minimize unnecessary carbapenem use, coupled with vigilant monitoring of high-risk patients, will be essential in combating the threat of CnSPA in healthcare settings. Declarations Consent for publication Not applicable. Competing Interest The authors declare no competing interests. Consent to participate Not applicable. Clinical trial number Not applicable. Author details Department of Laboratory Medicine, Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing 210008, China Funding This work was supported by Fundings for Clinical Trials from the Affiliated Drum Tower Hospital, Medical School of Nanjing University (2021-LCYJ-PY-06). Author Contribution All authors made a significant contribution to the work reported, Shuo Gao and Xuejing Xu putted forward the conception, Junbin Zhai, Xiaoli Cao and Chang Liu participated the study design, execution, acquisition of data, analysis and interpretation, or in all these areas; Yan Zhang and Jie Zheng took part in drafting, revising or critically reviewing the article; Xuejing Xu gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Data Availability The Whole Genome Shotgun BioProject for these isolates has been deposited at GenBank under submission SUB14182207, the accession number of each strain were as follows: JBBXIQ000000000, JBDHLK000000000, JBBXIP000000000, JBBXIO000000000, JBBXJL000000000, JBBXIN000000000, JBBXIM000000000, JBBXIL000000000, JBBXIK000000000, JBBXIJ000000000, JBBXII000000000, JBBXIH000000000, JBBXIG000000000, JBBXIF000000000, JBBXIE000000000, JBBXID000000000, JBBXIC000000000, JBBXIB000000000, JBBXIA000000000, JBBXHZ000000000, JBBXHY000000000, JBBXHX000000000, JBBXHW000000000, JBBXHV000000000, JBBXHU000000000, JBBXHT000000000, JBDHLJ000000000, JBBXHS000000000, JBBXHR000000000, JBCEYS000000000, JBBXJK000000000, JBBXJJ000000000, JBBXJI000000000, JBBXJH000000000, JBBXJG000000000, JBBXJF000000000, JBBXJE000000000, JBBXJD000000000, JBBXJC000000000, JBDHLN000000000, JBBXJB000000000, JBBXJA000000000, JBBXIZ000000000, JBBXIY000000000, JBBXIX000000000, JBBXIW000000000, JBBXIV000000000, JBDHLM000000000, JBDHLL000000000, JBBXIU000000000, JBBXIT000000000, JBBXIS000000000, JBBXIR000000000 Ethics approval This program has been approved by the Ethics Committee of the Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University (The approval number is 2023 − 390). 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Red bars indicate AMR gene pairs, while blue bars represent combinations of antimicrobial resistance genes and insertion sequences.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/9acbbac79d59e2a1fc5964ed.jpg"},{"id":92126009,"identity":"e198e1ad-51da-4fc4-9bac-018694818fe3","added_by":"auto","created_at":"2025-09-25 01:32:03","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":106615,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e oprD\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e Gene Mutations in Carbapenem-Non-Susceptible \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ePseudomonas aeruginosa\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e Clinical Isolates.\u003c/strong\u003e Each row represents an individual isolate, and each column corresponds to a specific amino acid substitution in the \u003cem\u003eoprD\u003c/em\u003egene. Blue dots indicate the presence of the respective mutation in a given isolate.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/ab3d9d10e3fcdd608725b7e0.jpg"},{"id":92126006,"identity":"b7cf5006-a5a8-43ca-a1c1-fe8f228e6fb8","added_by":"auto","created_at":"2025-09-25 01:32:03","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":103683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eampC\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e Gene Mutations Among 52 Carbapenem-Non-Susceptible \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ePseudomonas aeruginosa\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e Clinical Isolates\u003c/strong\u003e. Each row corresponds to an individual isolate, and each column represents a specific amino acid substitution. The presence of a mutation is indicated by a blue dot.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/9d0704fec5f211abbd301611.jpg"},{"id":92126012,"identity":"1f7f387b-3cd0-42c6-aa6f-7345af7d112c","added_by":"auto","created_at":"2025-09-25 01:32:03","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":46470,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003epbpC \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003eGene Mutations in Carbapenem-Non-Susceptible \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ePseudomonas aeruginosa \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003eClinical Isolates\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eEach row represents an individual isolate, and each column corresponds to a specific amino acid change within the\u003cem\u003epbpC \u003c/em\u003egene. The presence of a mutation is indicated by a blue triangle.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/2a09833a416aee0661521ac7.jpg"},{"id":104250638,"identity":"4c378051-f9dc-4ded-812f-3350d69b5ed8","added_by":"auto","created_at":"2026-03-09 16:03:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2623086,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/7361bfed-26ec-430e-9aaa-69ec1129695e.pdf"},{"id":92126015,"identity":"eedaf1c0-c83c-487c-960f-5f6b19b703c3","added_by":"auto","created_at":"2025-09-25 01:32:03","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":18901,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7307226/v1/184a1dbebd02142216fc9fb3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Genomic Characteristics and Risk Factor Analysis of Carbapenem-non-susceptible pseudomonas aeruginosa Causing Bacteremia in a Tertiary Hospital (2014-2023)","fulltext":[{"header":"1. Background","content":"\u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e is a ubiquitous opportunistic pathogen responsible for a range of severe infections, particularly in immunocompromised individuals \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Among these infections, bacteremia caused by this pathogen remains a significant concern due to its high morbidity and mortality rates \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The increasing prevalence of carbapenem-non-susceptible \u003cem\u003eP. aeruginosa\u003c/em\u003e (CnSPA) has further complicated treatment regimens, posing a critical challenge to healthcare systems globally \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCarbapenems are considered last-resort antibiotics for treating infections caused by multidrug-resistant Gram-negative bacteria \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, the emergence of CnSPA underscores the need to better understand the genetic mechanisms driving resistance and the associated clinical risk factors \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Resistance in CnSPA is often attributed to the overexpression of efflux pumps, loss of porins, or the acquisition of carbapenemase genes, which can be disseminated via mobile genetic elements \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. These genomic adaptations not only reduce treatment efficacy but also enhance the pathogen's fitness and adaptability.\u003c/p\u003e\u003cp\u003eEpidemiological studies have highlighted the importance of risk factor identification in preventing and managing CnSPA infections. Factors such as prolonged hospital stays, prior exposure to antibiotics, invasive procedures, and comorbidities are frequently linked to these infections \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Prior carbapenem treatment, in particular, has been suggested to exert selective pressure that promotes the emergence and spread of resistant strains; however, comprehensive analyses specifically focusing on this factor remain limited, especially in the context of bloodstream infections (BSIs).\u003c/p\u003e\u003cp\u003eThis study aims to bridge this gap by investigating the genomic features and risk factors of CnSPA strains isolated from BSIs in a tertiary hospital over a ten-year period (2014\u0026ndash;2023). By combining whole-genome sequencing (WGS) with clinical data analysis, including the evaluation of prior carbapenem exposure, we seek to identify key genetic determinants of resistance and delineate patient-related risk factors contributing to the spread of CnSPA. These findings will provide valuable insights for infection control strategies and antibiotic stewardship programs.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Bacterial strains\u003c/h2\u003e\u003cp\u003eA total of 52 consecutive and non-duplicate bloodstream isolates of CnSPA from our hospital between 2014 and 2023 were collected. Blood cultures were processed using the BD BACTEC\u0026trade; FX system (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) following standard clinical microbiology protocols. Positive cultures were subcultured onto blood agar (Oxoid, UK) and incubated at 37\u0026deg;C for 18\u0026ndash;24 hours under aerobic conditions. Colony morphology and Gram staining were assessed for preliminary identification, while species confirmation was performed using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, bioM\u0026eacute;rieux, France). Antimicrobial susceptibility testing was conducted using the microbroth dilution method, and interpretation of results followed the Clinical and Laboratory Standards Institute (CLSI), Performance Standards for Antimicrobial Susceptibility Testing, M100, 35th Edition. \u003cem\u003eEscherichia coli\u003c/em\u003e ATCC25922 was used as quality control.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Genomic extraction, whole genome sequencing and Genome Assembly\u003c/h2\u003e\u003cp\u003eGenomic DNA was extracted from overnight cultures of each \u003cem\u003eP. aeruginosa\u003c/em\u003e isolate grown on Luria-Bertani (LB) agar at 37\u0026deg;C for 18 hours using the TianGen Bacterial Genomic DNA Kit (Tiangen Biochemical Technology Co., Ltd., China) following the manufacturer\u0026rsquo;s protocol. DNA purity and concentration were assessed using a NanoDrop 2000 spectrophotometer and Qubit Fluorometer (Thermo Fisher Scientific, USA), while DNA integrity was evaluated by 1% agarose gel electrophoresis.\u003c/p\u003e\u003cp\u003eFor whole genome sequencing, DNA libraries were prepared using the NEBNext Ultra II DNA Library Prep Kit for Illumina and sequenced on an Illumina NovaSeq 6000 platform (Illumina, USA) with paired-end 150 bp reads, ensuring a minimum sequencing depth of 30\u0026times; coverage per genome. Raw sequencing reads underwent quality assessment with FastQC (v0.11.9) and trimming using Trimmomatic (v0.39). De novo genome assembly was performed using SPAdes (v3.15.4) with default parameters, and contigs were filtered for a minimum length of 500 bp. Assembly quality was assessed using QUAST (v5.0.2), and the final assembled genomes were submitted to GenBank.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Identification of Antibiotic Resistance Genes, Sequence Types, and Mobile Genetic Elements\u003c/h2\u003e\u003cp\u003eAntibiotic resistance genes (ARGs) were identified using ResFinder 4.1 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cge.food.dtu.dk/services/ResFinder/\u003c/span\u003e\u003cspan address=\"https://cge.food.dtu.dk/services/ResFinder/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) with a threshold of \u0026ge;\u0026thinsp;90% identity and \u0026ge;\u0026thinsp;60% coverage. Sequence types (STs) were determined using MLST 2.0 (v2.0.9, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cge.food.dtu.dk/services/MLST/\u003c/span\u003e\u003cspan address=\"https://cge.food.dtu.dk/services/MLST/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), with allele profiles retrieved from PubMLST.org. Mobile genetic elements (MGEs) were identified using Mobile Element Finder (v1.0.3, Database v1.0.2).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Whole-Genome Sequencing-Based Serotyping of P. aeruginosa\u003c/h2\u003e\u003cp\u003eWhole-genome sequences of the isolates were analyzed using the O-specific antigen (OSA) prediction method described by Thrane et al. \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e serotyper (PAst) tool was employed to assign serotypes based on genomic data. WGS data were screened for O-antigen biosynthesis gene clusters, and serotype assignment was conducted based on gene content and sequence homology. Additionally, serotype-specific gene markers were identified using a BLAST-based approach with reference sequences from known O-serotypes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Mutation analysis of carbapenem resistance related genes including oprD, ampC, pbpA and pbpC\u003c/h2\u003e\u003cp\u003eGenes associated with carbapenem resistance (\u003cem\u003eoprD\u003c/em\u003e, \u003cem\u003eampC\u003c/em\u003e, \u003cem\u003epbpA\u003c/em\u003e, and \u003cem\u003epbpC\u003c/em\u003e) were extracted from assembled genomes using a custom Python script and aligned with the reference strain \u003cem\u003eP. aeruginosa\u003c/em\u003e PAO1 (NC_002516.2) using MUSCLE (v3.8.1551) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Single nucleotide polymorphisms (SNPs), insertions, deletions, and frameshift mutations were identified using Snippy (v4.6.0), while their functional effects were predicted using SIFT (Sorting Intolerant from Tolerant) and PolyPhen-2 (Polymorphism Phenotyping v2)\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Clinical data collection\u003c/h2\u003e\u003cp\u003eClinical data of patients with confirmed CnSPA bloodstream infections (BSIs) were obtained from electronic medical records between 2014 and 2023. Inclusion criteria included a positive blood culture for CnSPA and availability of complete clinical data, while patients with incomplete medical records were excluded. The analyzed clinical variables included demographics (age, gender), comorbidities (hypertension, diabetes, malignancy, renal failure, open trauma), prior antibiotic use (carbapenems), presence of invasive devices (central venous catheters, mechanical ventilation), Intensive care unit (ICU) admission and recent surgeries, as well as length of hospital stay and clinical outcomes (mortality, infection resolution). Ethical approval for this study was obtained from the Ethics Committee of Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University (Approval No. 2023\u0026thinsp;\u0026minus;\u0026thinsp;390) and this study was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective and anonymized nature of the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Definitions\u003c/h2\u003e\u003cp\u003ePrimary BSI: Bloodstream infection with no identifiable infection source other than the bloodstream. Secondary BSI \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e: Bloodstream infection resulting from an infection at another site. Mixed Infections: CnSPA detected alongside other bacterial pathogens in the same blood culture or concurrent infections at different sites.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Statistical Analysis\u003c/h2\u003e\u003cp\u003eFor Risk Factor Analysis: Categorical variables were compared using chi-square tests or Fisher\u0026rsquo;s exact tests, and continuous variables were compared using t-tests or Mann-Whitney U tests as appropriate. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in univariate analysis were included in a multivariate logistic regression model to identify independent risk factors for CnSPA BSIs. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. For Prognostic Factors for CnSPA BSIs: Survival analysis was conducted using Kaplan-Meier curves to estimate survival probabilities, and the log-rank test was used to compare survival distributions. Cox proportional hazards regression was performed to identify independent prognostic factors for mortality in patients with CRPA BSIs. Hazard ratios (HRs) and 95% CIs were reported.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.1 The resistant rates of 52 CnSPA isolates\u003c/h2\u003e\u003cp\u003eResistance rates were highest against imipenem, with 98.1% of the strains resistant, followed by ciprofloxacin at 63.5%, and levofloxacin at 50.0%. Moderate resistance was observed against other antibiotics, including ticarcillin/clavulanic Acid (57.7%), Tazobactam/Piperacillin (40.4%), cefoperazone/sulbactam (38.5%), and meropenem (36.5%). Resistance to beta-lactams was also notable, with 23.1% of strains resistant to ceftazidime and 13.5% resistant to cefepime. Aminoglycosides showed varying resistance, with 13.5% of strains resistant to both amikacin and tobramycin. All the strains were susceptible to colistin (The resistant profiles were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and minimum inhibitory concentrations of 52 \u003cem\u003eP. aeruginosa\u003c/em\u003e are detailed in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\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\u003eThe sequence typing, serotype, resistance profile, and resistance gene of the 52 \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e isolates\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\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\u003eSequence typing\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSerotype\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eResistance profile\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eResistance gene\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2745\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-CSP-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, blaOXA-50, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3567\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUn\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aadA1, qacE, blaOXA-14, ant(2'')-Ia, sul1, blaPAO, aph(3')-IIb\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003eblaOXA-488, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eaadA1, blaOXA-14, ant(2')-Ia, qacE,sul1, ant(2')-Ia, blaPAO, aph\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(3')-IIb, crpP, blaOXA-488, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4591\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST348\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CSP-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4996\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, qacE, blaPAO, aph(3')-IIb, sul1, blaGES-1, aac(6')-Ib3, aph\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(3')-XV, aac(6')-Ib-cr, blaOXA-488, tet(G), catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST4003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-396, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5454\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUn\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaPAO, aph(3')-IIb, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5563\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST882\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, crpP, blaPAO, aph(3')-IIb, blaOXA-486, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6650\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST871\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6868\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST708\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-50, blaPAO, aph(3')-IIb, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaTEM-1B, aac(3)-IId, qacE, sul1, rmtB, blaPAO, aph(3')\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e-IIb, catB7, aadA13, cmlA1, aac(6')-IIa, crpP, aph(3'')-Ib, aph(6)-Id\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003eblaOXA-246, blaOXA-395\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM\u0026ndash;CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7318\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST390\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7339\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7409\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST606\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, crpP, blaPAO, aph(3')-IIb, blaOXA-488, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8681\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaPAO, aph(3')-IIb, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST316\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eblaOXA-395, aph(3')-IIb, blaPAO, fosA, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaTEM-1B, rmtB, aac(3)-IId, blaPAO, aph(3')-IIb, blaOXA\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e-246, aac(6')-IIa, aadA13, blaOXA-395, blaPER-1, dfrA1, aac(6')\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e-Ib-cr, aac(6')-Ib3, aadA2b, cmlA1, tet(C), aph(6)-Id, aph(3'')-Ib, sul1, qacE, aph(3')-Ia, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9524\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-CSP-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, catB7, blaOXA-486\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST532\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, blaOXA-395, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CSP-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, catB7, blaOXA-486\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST3382\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-488, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11638\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST2554\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST463\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-486, blaCARB-2, blaOXA-246, dfrA27, ARR-3, cmlA1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e, \u003cem\u003eant(2'')-Ia, crpP, blaPAO, aph(3')-IIb, crpP, qacE, sul1, aadA24\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003ecmlA1, aac(6')-II, blaKPC-2, catB7, aac(6')-IIa\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST3960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM-MEM-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-FEP-IPM-MEM-AMK-TOB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaVIM-2, aac(6')-Ib-cr, aac(6')-Ib3, blaOXA-10, aadA2b, crpP\u003c/em\u003e\u003c/p\u003e\u003cp\u003e, \u003cem\u003eblaPAO, aph(3')-IIb, blaOXA-488, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST379\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-494, blaOXA-50, blaOXA-396, blaPAO, aph(3')\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e-IIb\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST260\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eblaPAO, aph(3')-IIb, catB7, crpP, blaOXA-494, blaOXA-50, blaOXA\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e-396\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13910\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, tet(C), blaPAO, aph(3')-IIb, blaOXA-395, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14564\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, blaOXA-395, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaPAO, aph(3')-IIb, blaOXA-486, catB7, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14760\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-50, blaPAO, aph(3')-IIb\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1974\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTZP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaPAO, aph(3')-IIb, blaOXA-50\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, qacE, blaPAO, aph(3')-IIb, sul1, blaOXA-488, aadA6, crpP\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003ecatB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUn\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTZP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST281\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-486, blaPAO, aph(3')-IIb\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST3580\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, blaOXA-486\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST494\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST494\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CSP-IPM(I\u003csup\u003ec\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaPAO, aph(3')-IIb, blaOXA-486, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17767\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-486, blaPAO, aph(3')-IIb, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17774\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST1480\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST699\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, aph(3')-IIb, blaPAO, catB7, blaOXA-50\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18612\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST606\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CSP-IPM-MEM-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, aph(3')-IIb, blaPAO, blaOXA-488\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUn\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-50, blaPAO, aph(3')-IIb, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUn\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-CSP-IPM-MEM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, catB7, blaOXA-50, blaPAO, aph(3')-IIb, crpP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19686\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-TZP-CAZ-CSP-IPM-MEM-AMK-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, dfrA22, cmlA1, blaOXA-246, aac(6')-IIa, aph(3')-IIb, blaPAO\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003eaac(6')-II, aadA24, ant(2'')-Ia, cmlA1, msr(E), mph(E), blaOXA-396\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003eblaOXA-494, ARR-2, sul1, qacE, crpP, qnrVC1, dfrA27, catB7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19733\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eST244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eO5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTCC-IPM-MEM-TOB-CIP-LVX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003efosA, blaOXA-494, blaOXA-396, blaPAO, aph(3')-IIb, catB7, crpP\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e\u003cem\u003eaph(3'')-Ib, aph(6)-Id, aac(6')-IIa\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003eUnknown\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003eTCC, Ticarcillin-clavulanate; TZP, piperacillin-tazobactam; CAZ, ceftazidime; CSP, Cefoperazone-Sulbactam; FEP, cefepime; IMP, imipenem; MEM, meropenem; AMK, amikacin; TOB, tobramycin; CIP, Ciprofloxacin; LVX, levofloxacin;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ec\u003c/sup\u003eIntermediate\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Few carbapenemase encoding Genes were found in CnSPA strains\u003c/h2\u003e\u003cp\u003eTotally, 30 kinds of ARGs were found with \u003cem\u003ebla\u003c/em\u003ePAO (n\u0026thinsp;=\u0026thinsp;85), \u003cem\u003ebla\u003c/em\u003eOXA (n\u0026thinsp;=\u0026thinsp;71), \u003cem\u003eaph(3')\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;58), \u003cem\u003ecatB7\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;51), and \u003cem\u003efosA\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;51) being the most predominant ones (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In detail, among the 9 β-lactamase, three carbapenemase encoding genes including \u003cem\u003ebla\u003c/em\u003eKPC-2 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003eVIM-2 (n\u0026thinsp;=\u0026thinsp;1) and \u003cem\u003ebla\u003c/em\u003ePom-1 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003eOXA owned the most variants including \u003cem\u003ebla\u003c/em\u003eOXA-10 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003eOXA-14 (n\u0026thinsp;=\u0026thinsp;2), \u003cem\u003ebla\u003c/em\u003eOXA-246 (n\u0026thinsp;=\u0026thinsp;4), \u003cem\u003ebla\u003c/em\u003eOXA-395 (n\u0026thinsp;=\u0026thinsp;7), \u003cem\u003ebla\u003c/em\u003eOXA-396 (n\u0026thinsp;=\u0026thinsp;12), \u003cem\u003ebla\u003c/em\u003eOXA-486 (n\u0026thinsp;=\u0026thinsp;14), \u003cem\u003ebla\u003c/em\u003eOXA-488 (n\u0026thinsp;=\u0026thinsp;8), \u003cem\u003ebla\u003c/em\u003eOXA-494 (n\u0026thinsp;=\u0026thinsp;12) and \u003cem\u003ebla\u003c/em\u003eOXA-50 (n\u0026thinsp;=\u0026thinsp;11). \u003cem\u003ebla\u003c/em\u003eGES-1 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003eCARB-2 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003ePER-1 (n\u0026thinsp;=\u0026thinsp;1) and \u003cem\u003ebla\u003c/em\u003eTEM-1B (n\u0026thinsp;=\u0026thinsp;2) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3 \u003cem\u003eWide distribution of resistance genes and insertion sequences in the same contig\u003c/em\u003e\u003c/h2\u003e\u003cp\u003eInsertional sequences (ISs) are a class of transposons capable of encoding enzymes required for transposition, with short reverse terminal repeats at both ends. During transposition, the insertion sequence copies the target sequence and forms two short forward repeats on either side of the transposon. In this study, 50 of 52 \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e strains showed that the resistance gene was located on the same contig as the insertion sequence, which significantly increases the possibility of resistance gene transfer and suggests that the insertion sequence is a key mobile element mediating resistance gene transfer (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, five strains were found to contain six transposons. Among them, Tn5563 was identified in three strains, Tn5501 was found in one strain, and Tn4371 and Tn6082 were detected in two other strains, respectively. Furthermore, Tn5501 and Tn5563 were present in a single strain.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Diverse sequence types suggest the genetic diversity of CnSPA\u003c/h2\u003e\u003cp\u003eTotally, 36 distinct STs were identified with ST235 (n\u0026thinsp;=\u0026thinsp;3), ST244 (n\u0026thinsp;=\u0026thinsp;3), ST274 (n\u0026thinsp;=\u0026thinsp;3) and ST357 (n\u0026thinsp;=\u0026thinsp;3) were the most prevalent ones followed by ST1971 (n\u0026thinsp;=\u0026thinsp;2), ST606 (n\u0026thinsp;=\u0026thinsp;2), and ST494 (n\u0026thinsp;=\u0026thinsp;2). Other 29 STs were single. In addition, the ST type of 5 strains has not yet been determined (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Serotypes of 52 CnSPA Isolates\u003c/h2\u003e\u003cp\u003eThe serotyping analysis of 52 CnSPA isolates revealed a diverse distribution of O-antigen serotypes. Among these, O11 was the most prevalent, accounting for 15 isolates, followed by O6 (n\u0026thinsp;=\u0026thinsp;8), O1 (n\u0026thinsp;=\u0026thinsp;7), and O3 (n\u0026thinsp;=\u0026thinsp;7). Other detected serotypes exhibited varying degrees of prevalence (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Mutations may be the primary mechanism conferring non-susceptibility to carbapenem\u003c/h2\u003e\u003cp\u003eAmong the 52 CnSPA isolates, no mutations were detected in the \u003cem\u003eoprD\u003c/em\u003e gene of three isolates, while one isolate exhibited complete nonsense mutations in the \u003cem\u003eoprD\u003c/em\u003e gene. The remaining 48 isolates showed varying degrees of amino acid changes caused by \u003cem\u003eoprD\u003c/em\u003e gene mutations (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Additionally, mutations in the \u003cem\u003eampC\u003c/em\u003e gene led to amino acid alterations in 46 isolates (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), and mutations in the \u003cem\u003epbpC\u003c/em\u003e gene caused amino acid changes in 43 isolates (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). No mutations were detected in the \u003cem\u003epbpA\u003c/em\u003e gene among the 52 CnSPA isolates.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.7 Clinical features of 52 patients with CnSPA\u003c/h2\u003e\u003cp\u003eAmong the 52 patients included in the study, the highest numbers of cases occurred in 2017 and 2020, with seven cases each. The patient's ages ranged from 30 to 103 years, with a median age of 67 years. Male patients accounted for 69.2% (36 cases), with most being admitted to the intensive care unit (21.2%) or the geriatric department (17.3%). A majority of patients (92.3%, 48 cases) had hospital stays exceeding 10 days, and the overall prognosis was poor, with 38.5% (20 cases) dying during hospitalization. Comorbidities were common, as 76.9% (40 cases) of the patients had three or more underlying conditions, with hypertension being the most frequent (60%), followed by organ failure (45%), malignancy (37.5%), diabetes (30%), and open trauma (22.5%). Among the 32 patients with secondary bloodstream infections, over half (53.1%) originated from the lungs, while other infection sources included the urinary tract (12.5%), abdominal cavity (12.5%), biliary tract (9.4%), skin (9.4%), and catheters (3.1%). More than 30 patients underwent invasive procedures lasting over seven days, with intravenous catheterization being the most common (59.6%, 31 cases).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e3.8 Risk factors for Mortality and Co-Infection in CnSPA-BSI Patients: A Logistic Regression Analysis\u003c/h2\u003e\u003cp\u003eLogistic regression analysis showed that history of carbapenem antibiotic exposure (\u0026le;\u0026thinsp;90 days), organ failure, and mechanical ventilation (\u0026ge;\u0026thinsp;7 days) were independent risk factors for death in CnSPA-BSI patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Meanwhile, an indwelling catheter (\u0026ge;\u0026thinsp;7 days) was identified as an independent risk factor for bloodstream infection with CnSPA combined with other pathogens (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No independent risk factors for secondary CnSPA bloodstream infection were found in this study (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\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\u003eUnivariate and multivariate analysis of prognostic risk factors in the death and survival groups of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e bloodstream infection\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003evariate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath group (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurvival group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003esingle factor analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003emultiple-factor analysis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e/t value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR value (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOR value (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003egeneral information\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003egender (male) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (65.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.476\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.963\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.340\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCheck-in department (ICU) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (40.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.851\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.5 (23.0, 55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (17.0, 38.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.769\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of carbapenem antibiotic exposure (\u0026le;\u0026thinsp;90 days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (85.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (53.13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.975 (0.895\u0026thinsp;~\u0026thinsp;17.643)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5.000 (1.221\u0026thinsp;~\u0026thinsp;20.483)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eunderlying disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehigh blood pressure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.482\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\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 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.677\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emalignant tumor (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (45.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (18.75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.034 (0.578\u0026thinsp;~\u0026thinsp;15.930)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eopen wound (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (6.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.078 (1.076\u0026thinsp;~\u0026thinsp;60.627)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5.816 (0.904\u0026thinsp;~\u0026thinsp;37.395)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.064\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eorgan failure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (65.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (15.625%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.888 (2.834\u0026thinsp;~\u0026thinsp;78.220)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e14.077 (2.852\u0026thinsp;~\u0026thinsp;69.479)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave three or more underlying diseases (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (78.125%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.795\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003einvasive procedure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (56.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.790\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntravenous catheterization (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (53.125%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.456\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emechanical ventilation (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (31.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.436\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.122 (0.845\u0026thinsp;~\u0026thinsp;20.097)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5.133 (1.118\u0026thinsp;~\u0026thinsp;23.571)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eindwelling catheter (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (53.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.711\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.399\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\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\u003eUnivariate and multivariate analysis of prognostic risk factors for blood flow infection with \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e and other pathogens\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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=\"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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003evariate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e with other pathogens bloodstream infection (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSimple \u003cem\u003epseudomonas aeruginosa\u003c/em\u003e bloodstream infection (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003esingle factor analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003emultiple-factor analysis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e/t value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR value (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOR value (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003egeneral information\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003egender (male) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (68.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.888\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.714\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCheck-in department (ICU) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (59.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.853\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34.5 (21.0, 48.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.0 (17.0, 44.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of carbapenem antibiotic exposure (\u0026le;\u0026thinsp;90 days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16 (47.06%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (52.94%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.908\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.341\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eunderlying disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehigh blood pressure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (59.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (36.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediabetes (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (22.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (23.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.959\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emalignant tumor (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (18.18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (36.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.356\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.775 (0.163\u0026thinsp;~\u0026thinsp;3.676)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.748\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eopen wound (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (13.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.549\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eorgan failure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (36.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (33.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.821\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave three or more underlying diseases (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (86.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003einvasive procedure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16 (72.73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (46.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.793\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntravenous catheterization (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (77.27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (46.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.992\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.566 (0.354\u0026thinsp;~\u0026thinsp;6.927)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.554\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emechanical ventilation (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (59.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (36.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eindwelling catheter (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (86.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (36.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.422 (1.757\u0026thinsp;~\u0026thinsp;40.382)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10.939 (2.628\u0026thinsp;~\u0026thinsp;45.539)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\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\u003eUnivariate and multivariate analysis of prognostic risk factors for primary and secondary bloodstream infections with \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003evariate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary bloodstream infection group (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecondary bloodstream infection group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e/t value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003egeneral information\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003egender (male) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (65.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.476\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.0\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.799\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCheck-in department (ICU) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (53.125%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.271\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.602\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.0 (17.25, 42.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.0 (20.25, 55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.828\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.408\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of carbapenem antibiotic exposure (\u0026le;\u0026thinsp;90 days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (70.59%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.399\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eunderlying disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehigh blood pressure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (56.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.684\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.101\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\u003e3 (15.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (28.125%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.274\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emalignant tumor (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (21.875%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.141\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eopen wound (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eorgan failure (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (34.375%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.963\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave three or more underlying diseases (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (80%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.827\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003einvasive procedure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntravenous catheterization (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (59.375%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emechanical ventilation (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (53.125%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.627\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.202\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eindwelling catheter (\u0026ge;\u0026thinsp;7 days) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (62.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.788\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.374\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study insights into the genomic characteristics, resistance mechanisms, and clinical features of CnSPA strains, highlighting key findings and implications for clinical management and infection control strategies.\u003c/p\u003e\u003cp\u003eThe findings of this study reveal a concerning level of resistance among CnSPA isolates, with widespread β-lactam, fluoroquinolone, and aminoglycoside resistance, as well as the presence of MDR and XDR phenotypes. These resistance trends highlight the urgent need for innovative treatment strategies, rigorous infection control, and global surveillance efforts to curb the spread of CnSPA. Correspondingly, the identification of multiple resistance genes may provide explanation for the resistance.\u003c/p\u003e\u003cp\u003eOf note, only three carbapenemase-encoding genes were identified, each in a single isolate. This supports prior findings that carbapenemase production is not the predominant mechanism of carbapenem resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. In addition to the carbapenemase genes, other β-lactamase genes were also present but in very low numbers, further emphasizing that β-lactamase production is not the dominant mechanism in this cohort. Furthermore, our study showed that the \u003cem\u003ebla\u003c/em\u003eOXA family exhibited the greatest diversity. The widespread presence and diversity of \u003cem\u003ebla\u003c/em\u003eOXA variants may reflect the evolutionary adaptations of \u003cem\u003eP. aeruginosa\u003c/em\u003e in response to selective pressure from β-lactam antibiotics. Of note, most \u003cem\u003ebla\u003c/em\u003eOXA genes are not directly associated with carbapenem resistance, some variants, such as \u003cem\u003ebla\u003c/em\u003eOXA-50, have been linked to intrinsic resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Thus, the limited presence of carbapenemase-encoding genes in CnSPA indicate that non-carbapenemase-mediated resistance mechanisms, such as efflux pumps, porin mutations, and β-lactamase hyperproduction may confer resistance to carbapenems.\u003c/p\u003e\u003cp\u003eThe identification of 36 distinct STs among the 52 CnSPA isolates underscores the high genetic diversity of these strains. The most prevalent STs-ST235, ST244, ST274, and ST357 are globally recognized MDR clones frequently implicated in hospital outbreaks \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Among them, ST235, in particular, has been reported worldwide, often carrying \u003cem\u003ebla\u003c/em\u003eVIM and \u003cem\u003ebla\u003c/em\u003eKPC \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. ST244 is another well-documented high-risk clone associated with nosocomial infections and diverse resistance mechanisms \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Beyond these dominant STs, our study identified 29 unique STs, each represented by a single isolate, along with five undetermined STs. These rare STs may represent local or emerging clones with limited dissemination. Their presence highlights the continuous genetic evolution of \u003cem\u003eP. aeruginosa\u003c/em\u003e, driven by mutation accumulation, recombination, and horizontal gene transfer (HGT) \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Comparing our findings with prior epidemiological studies, ST235 and ST244 have been widely reported in China, Europe, and North America \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, while ST1971, ST606, and ST494 have been detected sporadically, suggesting a possible regional expansion of these clones \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The high frequency of unique STs may indicate local evolution within our hospital setting, possibly due to antibiotic selection pressure and adaptive responses to environmental conditions. Further WGS-based phylogenetic analyses will be necessary to track their transmission routes and evolutionary dynamics.\u003c/p\u003e\u003cp\u003eISs are key genetic elements promoting HGT, enabling the movement of resistance genes between plasmids, transposons, and chromosomes \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Our study found that 50 of 52 CnSPA isolates harbored resistance genes on the same contig as IS elements, indicating that ISs may facilitate rapid resistance gene transfer within \u003cem\u003eP. aeruginosa\u003c/em\u003e populations. Previous studies have shown that IS-mediated recombination plays a significant role in the dissemination of carbapenemase genes such as \u003cem\u003ebla\u003c/em\u003eVIM, \u003cem\u003ebla\u003c/em\u003eIMP, and \u003cem\u003ebla\u003c/em\u003eNDM\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. In our isolates, the strong association of IS elements with β-lactamase genes (\u003cem\u003ebla\u003c/em\u003eOXA, \u003cem\u003ebla\u003c/em\u003ePAO, \u003cem\u003ebla\u003c/em\u003eCARB) suggests that transposition events contribute to increased resistance gene mobility. Additionally, IS elements can activate adjacent resistance genes by introducing strong promoters, leading to increased gene expression and enhanced resistance phenotypes \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFrom an epidemiological perspective, the widespread presence of IS-associated ARGs raises concerns about cross-species gene transfer in hospital settings. ICU environments, where high antibiotic use and bacterial co-colonization are common, provide ideal conditions for such genetic exchanges \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. The ability of \u003cem\u003eP. aeruginosa\u003c/em\u003e to act as a resistance gene reservoir underscores the urgent need for enhanced infection control measures, including genomic surveillance to monitor IS-mediated resistance transmission.\u003c/p\u003e\u003cp\u003eAmong the identified serotypes, O11 was the most frequently detected, which is consistent with previous studies indicating that O11 is one of the most predominant serotypes in hospital-acquired \u003cem\u003eP. aeruginosa\u003c/em\u003e infections\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. This serotype is often associated with MDR, biofilm formation, and chronic infections, making it a major concern in nosocomial settings\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Similarly, O6, O1, and O3 serotypes were also frequently identified, reflecting their significant presence in clinical infections\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Previous reports have suggested that O6 is often linked to antibiotic resistance and increased virulence, while O1 and O3 have been associated with both acute and chronic infections\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. The relatively high prevalence of these serotypes suggests potential clonal expansion and highlights the need for continuous monitoring to track their epidemiological trends. The detection of multiple O-serotypes in this study suggests that CnSPA exhibits a high degree of serotypic variability, which may contribute to immune evasion, antimicrobial resistance, and adaptation to different host environments. This diversity could be driven by HGT, genetic recombination, or selective pressure from antibiotic use and host immune responses.\u003c/p\u003e\u003cp\u003eThe analysis of mutations in the \u003cem\u003eoprD\u003c/em\u003e, \u003cem\u003eampC\u003c/em\u003e, \u003cem\u003epbpC\u003c/em\u003e, and \u003cem\u003epbpA\u003c/em\u003e genes highlights their distinct contributions to carbapenem resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e. The widespread presence of \u003cem\u003eoprD\u003c/em\u003e mutations in 48 of 52 isolates, including frequent alterations such as E230K, S240T, N262T, E202Q, and I210A, suggests that OprD porin loss or functional impairment is the primary driver of carbapenem non-susceptibility\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. These findings align with prior research by Nazari et al. and and Fazeli et al\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. which reported significant \u003cem\u003eoprD\u003c/em\u003e downregulation in imipenem-resistant \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates. Mutations in \u003cem\u003eampC\u003c/em\u003e (46 isolates) and \u003cem\u003epbpC\u003c/em\u003e (43 isolates) were also prevalent, with the \u003cem\u003eampC\u003c/em\u003e T105A substitution being the most common. This finding is consistent with prior studies showing that \u003cem\u003eampC\u003c/em\u003e overexpression contributes to cephalosporin resistance and enhances \u003cem\u003eP. aeruginosa\u003c/em\u003e survival under antibiotic stress\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, \u003cem\u003epbpC\u003c/em\u003e mutations such as A104P may modify penicillin-binding protein function, further contributing to β-lactam resistance\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. The lack of significant mutations in \u003cem\u003epbpA\u003c/em\u003e suggests that it plays a limited role in resistance within this cohort. Overall, these findings reinforce the multifactorial nature of carbapenem resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e, where porin loss and β-lactamase overproduction work synergistically to reduce antibiotic efficacy.\u003c/p\u003e\u003cp\u003eIn addition, our study predominantly consisted of elderly patients, reflecting the vulnerability of older adults to \u003cem\u003eP. aeruginosa\u003c/em\u003e infections due to age-related immune decline, multiple comorbidities, and frequent hospital exposures\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. The predominance of a male was observed, potentially linked to biological or healthcare utilization differences. Most patients experienced extended hospital stays exceeding 10 days, indicating that prolonged hospitalization is both a risk factor for and a consequence of CnSPA infections. Admission to the ICU underscores the association of these infections with critically ill and vulnerable populations \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. The overall poor prognosis with a high mortality rate during hospitalization highlights the clinical severity of CnSPA infections, which may be often compounded by delays in effective treatment due to MDR. The common comorbidities likely increased susceptibility to infection. The high frequency of secondary BSI highlighted the opportunistic nature of CnSPA in exploiting multiple entry points\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. The common invasive procedures lasting over seven days emphasized medical devices as significant risk factors and reservoirs for nosocomial infections\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFurthermore, the independent risk factor identified in our study align with previous study. As we know that mechanical ventilation has been widely reported as a major risk factor for \u003cem\u003eP. aeruginosa\u003c/em\u003e BSIs due to its association with ventilator-associated pneumonia and nosocomial sepsis\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Shi Q et al. and Yuan Q et al. also identified prolonged mechanical ventilation as a key predictor of mortality in MDR \u003cem\u003eP. aeruginosa\u003c/em\u003e BSI patients\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. The underlying mechanisms include immune suppression from critical illness, microbial aspiration, and biofilm formation in ventilator circuits, all of which increase infection risk. Similarly, organ failure has been consistently linked to poor outcomes in bacterial sepsis. Dong L et al. demonstrated that sepsis-induced multi-organ dysfunction significantly increases mortality in \u003cem\u003eP. aeruginosa\u003c/em\u003e infections\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Importantly, our study further identified that prior exposure to carbapenem antibiotics (within 90 days) was an independent risk factor for mortality in patients with CnSPA BSIs. This finding directly supports the hypothesis raised in our introduction and corroborates prior studies indicating that previous carbapenem use exerts strong selective pressure, promoting the proliferation of resistant \u003cem\u003eP. aeruginosa\u003c/em\u003e strains\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e. In clinical practice, prior exposure to broad-spectrum antibiotics like carbapenems not only disrupts the normal flora but also facilitates the selection and expansion of resistant clones, thereby increasing the likelihood of adverse clinical outcomes\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e. The inclusion of this variable in our multivariate analysis reinforces its significance and provides actionable evidence for antimicrobial stewardship programs aimed at minimizing unnecessary carbapenem use to reduce mortality risk.\u003c/p\u003e\u003cp\u003eThe association of long-term catheterization with polymicrobial BSIs supports the notion that indwelling devices serve as bacterial reservoirs, facilitating biofilm formation and persistent colonization. This finding aligns with Buetti N et al.\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e, who found that prolonged catheterization significantly increases the risk of catheterization related BSIs, particularly in ICU patients. Interestingly, our study did not identify independent risk factors for secondary CnSPA BSIs, which contrasts with previous reports suggesting that prior colonization, immunosuppression, and prolonged antibiotic exposure may play key roles\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. This discrepancy may be due to differences in study design, sample size, or patient demographics, necessitating larger multi-center investigations to further explore secondary infection risk factors. Given these findings, early identification of high-risk patients and aggressive critical care management are crucial. Implementing ventilator stewardship programs, preventing and managing organ failure at an early stage, and adopting strict catheter management protocols can significantly reduce infection risks and improve patient outcomes.\u003c/p\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. First, it is a single-center study with a relatively small sample size, which may limit the generalizability of the findings to other healthcare settings or regions. Second, molecular analyses were focused on selected ARGs and mutations; thus, other genetic factors contributing to resistance such as overexpressed efflux pumps have been overlooked.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study elucidates the genomic diversity, resistance mechanisms, and clinical risk factors associated with CnSPA BSIs. We found that carbapenem resistance in \u003cem\u003eP. aeruginosa\u003c/em\u003e is driven primarily by \u003cem\u003eoprD\u003c/em\u003e, \u003cem\u003eampC\u003c/em\u003e, and \u003cem\u003epbpC\u003c/em\u003e mutations rather than carbapenemase production. The high genetic diversity of STs, along with the widespread presence of IS elements facilitating HGT, underscores the urgent need for genomic surveillance. Furthermore, the identification of mechanical ventilation, prior carbapenem exposure (\u0026le;\u0026thinsp;90 days) and organ failure as mortality risk factors reinforces the importance of early clinical intervention to improve patient outcomes. Targeted efforts to minimize unnecessary carbapenem use, coupled with vigilant monitoring of high-risk patients, will be essential in combating the threat of CnSPA in healthcare settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eCompeting Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent to participate\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003cp\u003eDepartment of Laboratory Medicine, Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing 210008, China\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by Fundings for Clinical Trials from the Affiliated Drum Tower Hospital, Medical School of Nanjing University (2021-LCYJ-PY-06).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors made a significant contribution to the work reported, Shuo Gao and Xuejing Xu putted forward the conception, Junbin Zhai, Xiaoli Cao and Chang Liu participated the study design, execution, acquisition of data, analysis and interpretation, or in all these areas; Yan Zhang and Jie Zheng took part in drafting, revising or critically reviewing the article; Xuejing Xu gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe Whole Genome Shotgun BioProject for these isolates has been deposited at GenBank under submission SUB14182207, the accession number of each strain were as follows: JBBXIQ000000000, JBDHLK000000000, JBBXIP000000000, JBBXIO000000000, JBBXJL000000000, JBBXIN000000000, JBBXIM000000000, JBBXIL000000000, JBBXIK000000000, JBBXIJ000000000, JBBXII000000000, JBBXIH000000000, JBBXIG000000000, JBBXIF000000000, JBBXIE000000000, JBBXID000000000, JBBXIC000000000, JBBXIB000000000, JBBXIA000000000, JBBXHZ000000000, JBBXHY000000000, JBBXHX000000000, JBBXHW000000000, JBBXHV000000000, JBBXHU000000000, JBBXHT000000000, JBDHLJ000000000, JBBXHS000000000, JBBXHR000000000, JBCEYS000000000, JBBXJK000000000, JBBXJJ000000000, JBBXJI000000000, JBBXJH000000000, JBBXJG000000000, JBBXJF000000000, JBBXJE000000000, JBBXJD000000000, JBBXJC000000000, JBDHLN000000000, JBBXJB000000000, JBBXJA000000000, JBBXIZ000000000, JBBXIY000000000, JBBXIX000000000, JBBXIW000000000, JBBXIV000000000, JBDHLM000000000, JBDHLL000000000, JBBXIU000000000, JBBXIT000000000, JBBXIS000000000, JBBXIR000000000\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003e This program has been approved by the Ethics Committee of the Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University (The approval number is 2023\u0026thinsp;\u0026minus;\u0026thinsp;390). The need of informed consent was waived by the Ethics Committee of the Nanjing Drum Tower Hospital due to anonymous and retrospective study design. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Sousa T, H\u0026eacute;braud M, Dapkevicius M, Maltez L, Pereira JE, Capita R, Alonso-Calleja C, Igrejas G, Poeta P. Genomic and Metabolic Characteristics of the Pathogenicity in Pseudomonas aeruginosa. Int J Mol Sci 2021, 22(23).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFalcone M, Tiseo G, Carbonara S, Marino A, Di Caprio G, Carretta A, Mularoni A, Mariani MF, Maraolo AE, Scotto R, et al. Mortality Attributable to Bloodstream Infections Caused by Different Carbapenem-Resistant Gram-Negative Bacilli: Results From a Nationwide Study in Italy (ALARICO Network). 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Published 2024 Nov 13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYuan Q, Guo L, Li B, et al. Risk factors and outcomes of inpatients with carbapenem-resistant Pseudomonas aeruginosa bloodstream infections in China: a 9-year trend and multicenter cohort study. Front Microbiol. 2023;14:1137811. Published 2023 May 18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDong L, Huang Y, Zhang S, Xu B, Li B, Cao Y. Risk Factors for Development and Mortality of Carbapenem-Resistant Pseudomonas aeruginosa Bloodstream Infection in a Chinese Teaching Hospital: A Seven-Year Retrospective Study. Infect Drug Resist. 2025;18:979\u0026ndash;91. Published 2025 Feb 18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbejew AA, Wubetu GY, Fenta TG. Relationship between Antibiotic Consumption and Resistance: A Systematic Review. Can J Infect Dis Med Microbiol. 2024;2024:9958678. Published 2024 Mar 5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeletis G, Vavatsi N, Exindari M, et al. Accumulation of carbapenem resistance mechanisms in VIM-2-producing Pseudomonas aeruginosa under selective pressure. Eur J Clin Microbiol Infect Dis. 2014;33(2):253\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYuan Q, Guo L, Li B, et al. Risk factors and outcomes of inpatients with carbapenem-resistant Pseudomonas aeruginosa bloodstream infections in China: a 9-year trend and multicenter cohort study. Front Microbiol. 2023;14:1137811. Published 2023 May 18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuetti N, Timsit JF. Management and Prevention of Central Venous Catheter-Related Infections in the ICU. Semin Respir Crit Care Med. 2019;40(4):508\u0026ndash;23.\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-microbiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mcro","sideBox":"Learn more about [BMC Microbiology](http://bmcmicrobiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mcro","title":"BMC Microbiology","twitterHandle":"#bmcmicrobiology","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Carbapenem-non-susceptible Pseudomonas aeruginosa, bloodstream infections, carbapenem resistance, oprD mutations, antimicrobial resistance, whole genome sequencing, risk factors","lastPublishedDoi":"10.21203/rs.3.rs-7307226/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7307226/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eCarbapenem-non-susceptible \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (CnSPA) bloodstream infections (BSIs) are associated with high mortality and present significant clinical and public health challenges. This study aimed to investigate the genomic characteristics, resistance mechanisms, clinical features, and risk factors associated with CnSPA BSIs.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA total of 52 consecutive, non-duplicate CnSPA isolates causing BSIs were collected from 2014 to 2023. Whole genome sequencing (WGS) was conducted to analyze antimicrobial resistance genes, sequence types (STs), serotypes, and mutations in carbapenem resistance-associated genes (\u003cem\u003eoprD\u003c/em\u003e, \u003cem\u003eampC\u003c/em\u003e, \u003cem\u003epbpA\u003c/em\u003e, \u003cem\u003epbpC\u003c/em\u003e). Clinical data were collected to identify patient demographics, comorbidities, invasive procedures, and outcomes. Statistical analyses included logistic regression for risk factor identification and survival analysis for prognostic factors.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eAmong the 30 kinds of ARGs found, three carbapenemase encoding genes including \u003cem\u003ebla\u003c/em\u003eKPC-2 (n\u0026thinsp;=\u0026thinsp;1), \u003cem\u003ebla\u003c/em\u003eVIM-2 (n\u0026thinsp;=\u0026thinsp;1) and \u003cem\u003ebla\u003c/em\u003ePom-1 (n\u0026thinsp;=\u0026thinsp;1) were identified. Genomic analysis revealed 36 distinct STs, with ST235, ST244, ST274, and ST357 being the most prevalent. Insertion sequences (ISs) were co-located with resistance genes in 96.2% of isolates, indicating a high potential for horizontal gene transfer. The serotypes analysis revealed a diverse distribution of O-antigen serotypes, with O11 (n\u0026thinsp;=\u0026thinsp;15) being the most prevalent. \u003cem\u003eoprD\u003c/em\u003e gene mutations were found in 92.3% of isolates. Mutations in \u003cem\u003eampC\u003c/em\u003e (88.5%) and \u003cem\u003epbpC\u003c/em\u003e (82.7%) contributed to resistance, but no \u003cem\u003epbpA\u003c/em\u003e mutations were detected. Clinically, the median patient age was 67 years, with male predominance (69.2%) and high mortality (38.5%). Logistic regression identified prolonged mechanical ventilation (\u0026ge;\u0026thinsp;7 days), History of carbapenem antibiotic exposure (\u0026le;\u0026thinsp;90 days) and organ failure as independent risk factors for mortality, while prolonged indwelling catheterization (\u0026ge;\u0026thinsp;7 days) was an independent risk factor for polymicrobial infections.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eOur study showed that carbapenem resistance in CnSPA is predominantly driven by \u003cem\u003eoprD\u003c/em\u003e inactivation and other gene mutations rather than carbapenemase production. The high genetic diversity among isolates emphasizes the need for robust genomic surveillance. Clinically, prolonged invasive procedures and critical illness contribute to adverse outcomes, underscoring the importance of infection control measures and timely management. These findings provide valuable insights into guiding antimicrobial stewardship and improving clinical outcomes for CnSPA BSI patients.\u003c/p\u003e","manuscriptTitle":"Genomic Characteristics and Risk Factor Analysis of Carbapenem-non-susceptible pseudomonas aeruginosa Causing Bacteremia in a Tertiary Hospital (2014-2023)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 01:31:58","doi":"10.21203/rs.3.rs-7307226/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-30T04:46:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T06:16:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300812565849381765219034312027069240266","date":"2025-10-13T18:00:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T20:01:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13918209631888337284624646041358402673","date":"2025-09-18T18:40:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-16T05:18:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T11:40:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-27T06:22:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T09:30:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Microbiology","date":"2025-08-25T09:26:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-microbiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mcro","sideBox":"Learn more about [BMC Microbiology](http://bmcmicrobiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mcro","title":"BMC Microbiology","twitterHandle":"#bmcmicrobiology","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"856b9c06-cced-40a5-8b1e-d3a1d2e6532b","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:01:15+00:00","versionOfRecord":{"articleIdentity":"rs-7307226","link":"https://doi.org/10.1186/s12866-026-04747-9","journal":{"identity":"bmc-microbiology","isVorOnly":false,"title":"BMC Microbiology"},"publishedOn":"2026-03-02 15:57:30","publishedOnDateReadable":"March 2nd, 2026"},"versionCreatedAt":"2025-09-25 01:31:58","video":"","vorDoi":"10.1186/s12866-026-04747-9","vorDoiUrl":"https://doi.org/10.1186/s12866-026-04747-9","workflowStages":[]},"version":"v1","identity":"rs-7307226","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7307226","identity":"rs-7307226","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}