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Background: Carbapenem-resistant Enterobacteriaceae (CRE) represent a significant antibiotic resistance threat, in part because carbapenemase genes can spread on mobile genetic elements. Here, we describe the molecular epidemiology and outcomes of patients with CRE bacteriuria from the same city in a nonoutbreak setting. Methods: The Georgia Emerging Infections Program performs active, population-based CRE surveillance in Atlanta. We studied a cohort of patients with CRE (resistant to all tested third-generation cephalosporins and ≥1 carbapenem, excluding ertapenem) first identified in urine, and not in a prior or simultaneous sterile site, between 2012 and 2015. Whole-genome sequencing (WGS) was performed on a convenience sample. We obtained epidemiologic and outcome data through chart review and Georgia Vital Statistics records (90-day mortality). Using WGS, we created a core-genome alignment-based phylogenetic tree of the Klebsiella pneumoniae isolates and calculated the SNP difference between each sample. Using SAS version 9.4 software, we performed the Fisher exact test and univariable odds ratios (OR) with 95% CI to compare patient isolates with and without a carbapenemase gene. Results: Among 81 patients included, the median age was 68 (IQR, 57–74) years, and most were female (58%), black (60%), and resided in a long-term care facility 4 days prior to culture isolation (53%). Organisms isolated were K. pneumoniae (84%), Escherichia coli (7%), Enterobacter cloacae (7%), and Klebsiella oxytoca (1%). WGS identified at least 1 β-lactamase gene in 91% of the isolates; 85% contained a carbapenemase gene, the most frequent of which was blaKPC-3 (94%). Patients with CRE containing a carbapenemase gene were more likely to be black (OR, 3.7; 95% CI, 1.0–13.8) and to have K. pneumoniae (OR, 8.9; 95% CI, 2.2–35.0). Using a core-genome alignment of 3,708 genes (~63% of the complete genome), we identified a median of 67 (IQR, 23–3,881) SNP differences between each K. pneumoniae isolate. A phylogenetic tree identified clustering around carbapenemase gene and multilocus sequence type (84% were ST 258) but not based on referring laboratory or county of residence (Fig. 1). Although 7% of patients developed an invasive CRE infection within 1 year and 21% died within 90 days, having a carbapenemase gene was not associated with these outcomes. Conclusions: Molecular sequencing of a convenience sample of CRE bacteriuria support K. pneumoniae ST258 harboring blaKPC-3 being distributed throughout the Atlanta area, across the healthcare continuum. Overall mortality was high in this population, but the presence of carbapenemase genes was not associated with worse outcomes.
Glacial retreat in response to warming climates in the arid Xinjiang region of northwestern China directly impacts downstream water resources available for local communities. We used high-resolution satellite imagery from 1969 to 2014 to delineate spatial changes in 54 active glaciers in the upper Kaidu River Basin in the Tian Shan as well as their past expanses during the Little Ice Age (LIA). We manually delineated their boundaries based on the interpretation of glacial, geomorphic and topographic features. From the total glacier surface area, we estimated glacier volume and mass. From 1969 to 2014, glacier area decreased by 10.1 ± 1.0 km2 (relative loss of 34.2 ± 3.5%) and mass by 1.025 ± 0.108 Gt (relative loss of 43 ± 4.6%). From the LIA maximum (est. 1586 CE) to 1969, relative losses were less (25.7 ± 4.3% area loss and 33.1 ± 5.7% mass loss). Our results indicate that glacier recession is accelerating over time and that the glaciers are currently losing over 1.5 times more relative area than elsewhere in the Tian Shan. Using linear and non-linear projections, we estimate that these glaciers may disappear between 2050 and 2150 CE if climatic warming continues at the same pace.
Communication Skills for Business Professionals, second edition, is a student-friendly introduction to effective communication in the workplace. Engagingly written, the text covers foundational topics such as audience, influence, channels, conflict and persuasion, before investigating more complex areas such as intercultural communication, virtual communication, researching in the era of 'fake news' and strategies for successful written communication. Taking a broad and current approach to concepts of communication and workplaces, Communication Skills for Business Professionals explores situations from virtual meetings between indie creatives, to speeches given by politicians, while still covering more traditional forms of professional communication, such as pitching to boards and memos. New pedagogical features such as skill builder class activities, margin definitions and links to online content make this book indispensable for teachers and students of communications alike.