1.Study on radioprotection of indole-3-carbinol acid condensation products
Xiaofei CHU ; Shuyi ZHAO ; Ming CUI ; Lu LU ; Junling ZHANG ; Qinghui MENG ; Saijun FAN
International Journal of Biomedical Engineering 2016;39(3):144-148
Objective To study the radioprotective effect of indole-3-carbinol (I3C) acid condensation products.Methods Cell colony formation assay was used to determine cell survival rate,and Western Blot assay was employed to measure protein expression.Results Seven kinds of the I3C acid condensation products showed different radioprotective effect on normal fibrous epithelial cells 184A1,among which 24 h pre-treatment of CTET (1 μmol/L),LTET (1 μmol/L),HI-IM (1 μmol/L) and 3,3'-diindoly methane (DIM) (0.3 μmol/L) showed significant increase of cell survival rate following irradiation with γ-ray,and the difficence was statistically significant (P<0.05,P<0.01).However,CT (1 μmol/L),LTr-1 (1 μmol/L) and ICZ (1 μmol/L) showed no effect on cell survival rate caused by radiation (P>0.05).Furthermore,CTET,LTET,HI-IM and DIM activated the phosphorylation of ATM,BRCA1 and NBS1 proteins.HI-IM significantly decreased radiation-caused cell death and apoptosis.Conclusions CTET,LTET,HI-IM,and DIM can significantly reduce the radiosensitivity in 184A1 cells,and the mechanism may be related to the regulation of DNA damage and the repair of protein phosphorylation.
2.Study of the impact of CLPTM1L on radiosensitivity of lung cancer
Shuyi ZHAO ; Xiaofei CHU ; Weili LIU ; Qinghui MENG ; Ming CUI ; Saijun FAN
International Journal of Biomedical Engineering 2016;39(3):149-152
Objective To study the correlation of cleft lip and palate transmembrane 1 like(CLPTM1L)expression and radiosensitivity of lung cancer cells.Methods Thiazolyl blue tetrazolium bromide(MTT) and cell colony formation assays were used to determine cell growth and survival.Western Blot assay was employed to measure protein expression.Results The results demonstrated a negative correlation between the CLPTM1L expression level and radiosensitivity of lung cancer cells.A lower radiosensitivity in lung cancer cells containing high level of CLPTM1L expression,and vice versa.Enforced expression of CLPTM1L resulted in a significant reduction of radiosensitivity in lung cancer cells irradiated with γ-rays.On the contrary,a marked elevation of radiosensitivity was observed in lung cancer cells transfected with CLPTM1L siRNA.Conclusions CLPTM1L may be a novel target gene in mediating radiosensitivity of lung cancer cells.
3.The mediating effect of interdisciplinary cooperation ability on the level of hospice care practice and the degree of difficulty of medical staff
Jia JIA ; Xiaofei NIE ; Kang GAO ; Fanfan LYU ; Longti LI ; Yongqiao XIE ; Chu LI ; Lu XU
Chinese Journal of Practical Nursing 2023;39(19):1485-1492
Objective:To explore the mediating role of interdisciplinary cooperation ability between the level of hospice care practice and difficulty degree of hospice care for medical staff, in order to improve the quality of hospice care services for medical staff, and to provide evidence for relevant managers to formulate effective measures to reduce the implementation of hospice care difficulties.Methods:This study was a cross-sectional survey. Using convenience sampling method, the general data questionnaire, Palliative Care Difficulties Scale (PCDS), Palliative Care Self-Report Practice Scale (PCPS) and Modified Index of Interdisciplinary Collaboration (MIIC) were used to investigate 362 medical staff in all hospice care institutions of Shiyan City from July to August 2022.Results:The total score of PCDS in 362 medical staff was (40.58±13.44) points, (67.47 ± 12.50) points for PCPS and (108.36 ± 21.46) points for MIIC. There was a positive correlation between the total score of MIIC and PCDS ( r=0.500, P<0.01). The total score of PCPS was negatively correlated with the total score of MIIC ( r=-0.337, P<0.01) and the total score of PCDS ( r=-0.189, P<0.01). The interdisciplinary cooperation ability of medical staff in hospice care had a complete mediating effect between the level of practice and the degree of difficulty (Effect value=-0.190, 95% CI-0.274 to -0.126), and the mediating effect accounted for 98.5% of the total effect value. Conclusions:The practice level of hospice care can not directly affect the implementation of the difficulty degree, but by taking active measures to improve the interdisciplinary cooperation ability, so as to enhance the practice level, and then reduce the implementation of hospice care difficulty degree.
4.Analysis on prevalence states and associated factors of hypertension and prehypertension among adults in Shandong province.
Jie CHU ; Linhong WANG ; Aiqiang XU ; Yichong LI ; Huicheng WANG ; Xiaolei GUO ; Zilong LU ; Xiaofei ZHANG ; Jiyu ZHANG ; Jixiang MA ; Zhenqiang BI
Chinese Journal of Preventive Medicine 2014;48(1):12-17
OBJECTIVETo analyze the prevalence states of hypertension and prehypertension and to explore relevant influencing factors among adult residents in Shandong province.
METHODS15 600 residents aged between 18 and 69 from 20 counties in Shandong province were selected by multiple stratified and clustered sampling method from July to September, in 2011, to acquire related information by questionnaire survey and physical measurement. The prevalence of hypertension and prehypertension was estimated by special statistic method used to deal with complex sampling data, and the relevant influencing factors were also analyzed.
RESULTSA total of 15 350 subjects were actually completed the survey, with age at (41.4 ± 14.1) years old. The average systolic blood pressure and diastolic blood pressure were 121.1(95%CI: 119.7-122.4) and 78.8(95%CI: 77.8-79.9) mmHg (1 mmHg = 0.133 kPa) respectively. And also 3776 hypertension patients and 5721 subjects with prehypertension were detected, and the weighting prevalence of hypertension and prehypertension were 23.4% (95%CI: 20.9%-26.0%) and 37.1% (95%CI: 34.7%-39.5%) with adjustive prevalence at 20.7% and 36.5% respectively. The multiple SURVEYLOGISTIC analysis showed that age above 40 years old (OR = 3.24, 95%CI: 2.56-4.10), overweight(OR = 2.22, 95%CI: 1.70-2.89) and obesity(OR = 5.84, 95%CI: 3.54-9.66), smoking history(OR = 1.82, 95%CI: 1.03-3.23), constantly drinking (OR = 1.71, 95%CI: 1.08-2.70), diabetes (OR = 1.99, 95%CI: 1.29-3.07), abnormal TC(OR = 1.64, 95%CI: 1.24-2.17), abnormal TG(OR = 1.75, 95%CI: 1.24-2.48) and high 24 h urine Na/K ratio (OR = 1.05, 95%CI: 1.02-1.08) were risk factors of hypertension, while education equal to or above junior middle school (OR = 0.68, 95%CI: 0.52-0.89) was protective factor of hypertension; age above 40 years old (OR = 1.49, 95%CI: 1.15-1.91), overweight(OR = 1.76, 95%CI: 1.25-2.48) and obesity (OR = 3.50, 95%CI: 2.05-5.97), abnormal TC (OR = 1.54, 95%CI: 1.10-2.14), abnormal TG (OR = 1.79, 95%CI:1.25-2.56) and high 24 h urine Na/K ratio (OR = 1.02, 95%CI: 1.01-1.04) were risk factors of prehypertension, while female (OR = 0.41, 95%CI: 0.31-0.56) and education level equal to or above junior middle school (OR = 0.67, 95%CI: 0.52-0.87) were protective factors.
CONCLUSIONThe hypertension, especially prehypertension tends to be at high prevalence states currently, which may be affected by many factors.
Adolescent ; Adult ; Aged ; China ; epidemiology ; Cross-Sectional Studies ; Female ; Humans ; Hypertension ; epidemiology ; Male ; Middle Aged ; Prehypertension ; epidemiology ; Risk Factors ; Young Adult
5.Dietary sodium intakes and resources among residents in Shandong province.
Zilong LU ; Xiaofei ZHANG ; Jianhong LI ; Jiyu ZHANG ; Wenhua ZHAO ; Jixiang MA ; Xiaolei GUO ; Liuxia YAN ; Jie CHU ; Aiqiang XU
Chinese Journal of Preventive Medicine 2014;48(1):7-11
OBJECTIVETo describe dietary sodium intakes and resources among residents in Shandong province.
METHODSA total of 2184 subjects were selected by multi-stage stratified cluster random sampling method from 18-69 years old people in Shandong province in June, 2011. A total of 2140 subjects completed the study, the completion rate was 98.0%. Three-day (24-hour per day) dietary recalls and weighting methods were conducted to collect information about all the foods and condiments consumed by the subjects. Individual dietary sodium intake was calculated, the differences of dietary sodium intake among subjects with different characteristics were analyzed, and the proportions of different dietary sodium resources were also analyzed.
RESULTSThe amount of individual dietary sodium intake was 5745.0 (95%CI:5427.6-6062.5) mg/d in Shandong; 6147.4 (95%CI: 5823.8-6471.0) mg/d for male residents, 5339.3 (95%CI:5005.8-5672.8) mg/d for female residents. There was a significant difference between males and females (F = 75.22, P < 0.01). The amount of individual dietary sodium intake was 5910.1 (95%CI:5449.3-6370.8) mg/d, 5341.6 (95%CI:5007.0-5676.1) mg/d for rural residents and urban residents respectively, and there was also a significant difference (F = 5.53, P < 0.05). The amount of condiment sodium intake was 4640.3 (95%CI:4360.2-4920.4) mg/d, which was the largest contributor to sodium intake, accounting for 80.8% (95%CI:79.9%-81.6%) of total intake. Sodium intake from cereals was 650.7 (95%CI: 590.5-711.0) mg/d, accounting for 11.3% (95%CI:10.3%-12.3%) of total intake. Sodium intake from eggs was 118.9 (95%CI:95.2-142.6) mg/d, accounting for 2.1% (95%CI:1.6%-2.6%) of total intake. The amount of manufactured food sodium intake was 582.1(95%CI: 497.8-666.4) mg/d, accounting for 10.1% (95%CI:8.9%-11.4%) of total intake.
CONCLUSIONSodium intakes remain high among residents of Shandong province, and sodium from condiments was the largest source of dietary sodium intake, sodium of manufactured food only accounting for small part.
Adolescent ; Adult ; Aged ; China ; Condiments ; Cross-Sectional Studies ; Diet Surveys ; Female ; Humans ; Male ; Middle Aged ; Sodium, Dietary ; Young Adult
6.Relationship between perioperative cardiovascular events and serum TRPV1, CGRP and SP concentrations in patients with diabetic peripheral neuropathy
Xiaofei CHU ; Xiangfeng ZHAO ; Wentao DENG ; Zheng GUO
Chinese Journal of Anesthesiology 2020;40(2):146-150
Objective:To evaluate the relationship between perioperative cardiovascular events and serum transient receptor potential vanilloid 1 (TRPV1), calcitonin gene-related peptide (CGRP) and substance P (SP) concentrations in the patients with diabetic peripheral neuropathy (DPN).Methods:Twenty-eight patients with type 2 diabetes mellitus (DM) complicated by DPN undergoing elective non-cardiovascular surgery under general anesthesia, were enrolled in DPN group, and 28 patients with type 2 DM without DPN were included in DM group.Another 28 nondiabetic patients undergoing non-cardiovascular elective surgery under general anesthesia were selected as control group (C group). The patients were 55 to 81 years old and classified as American Society of Anesthesiologists physical status Ⅱ or Ⅲ, regardless of gender.The development of cardiovascular events during surgery and within 24 h after surgery and use of vasoactive drugs were recorded.Venous blood samples were taken at 30 min before anesthesia induction and 24 h after surgery for determination of the concentrations of TRPV1, CGRP, SP and cardiac troponin I (cTnI) in serum using enzyme-linked immunosorbent assay.Results:Compared with group C, the incidence of perioperative cardiovascular events and utilization rate of vasoactive drugs were significantly increased, the preoperative concentrations of serum TRPV1, CGRP and SP were decreased, and the postoperative concentration of serum cTnI was increased in DM and DPN groups ( P<0.05). Compared with DM group, the incidence of perioperative cardiovascular events was significantly increased, the preoperative concentrations of serum TRPV1, CGRP and SP were decreased, the postoperative concentration of serum cTnI was increased ( P<0.05), and no significant change was found in the utilization rate of vasoactive drugs in DPN group ( P>0.05). The postoperative cTnI concentrations in serum were negatively correlated with the preoperative TRPV1, CGRP and SP concentrations in serum in DPN group ( P<0.01). Conclusion:The increased risk of perioperative cardiovascular events may be related to the decrease in serum TRPV1, CGRP and SP concentrations in DPN patients.
7.Relationship between TRPV1 gene polymorphism and genetic susceptibility to type 2 diabetes mellitus and intraoperative adverse cardiovascular events
Xiangfeng ZHAO ; Wentao DENG ; Xiaofei CHU ; Zheng GUO
Chinese Journal of Anesthesiology 2020;40(5):557-560
Objective:To determine the relationship between transient receptor potential vanilloid 1 (TRPV1) gene polymorphism and genetic susceptibility to type 2 diabetes mellitus (DM) and intraoperative adverse cardiovascular events (ACVEs).Methods:Eighty-six DM patients and 78 non-DM patients (nDM) undergoing elective knee replacement or posterior lumbar interbody fusion were selected in this study.Real-time fluorescence quantitative polymerase chain reaction was carried out to genotype the rs222747 variant of TRPV1 gene.The ACVEs occurred were recorded during operation, and the risk factors for ACVE developed during operation were identified.Results:Compared with nDM group, the TRPV1 genotype G/G ratio, allele G frequency, and incidence of intraoperative ACVE were significantly increased in DM group ( P<0.05). Aging and TRPV1 genotype GG combined with DM were the risk factors for intraoperative ACVEs occurred ( P<0.05). Conclusion:TRPV1 gene polymorphism is related to the genetic susceptibility to type 2 DM and occurrence of intraoperative ACVEs.
8.Changing susceptibility ofKlebsiella strains in hospitals across China:data from the CHINET Antimicrobial Resistance Surveillance Program, 2005-2014
An XU ; Chao ZHUO ; Danhong SU ; Fupin HU ; Demei ZHU ; Fu WANG ; Xiaofei JIANG ; Yingchun XU ; Xiaojiang ZHANG ; Ziyong SUN ; Zhongju CHEN ; Yuxing NI ; Jingyong SUN ; Zhidong HU ; Jin LI ; Zhaoxia ZHANG ; Ping JI ; Chuanqing WANG ; Aimin WANG ; Qing YANG ; Yuanhong XU ; Jilu SHEN ; Bin SHAN ; Yan DU ; Hong ZHANG ; Jing KONG ; Lianhua WEI ; Ling WU ; Yi XIE ; Mei KANG ; Yunjian HU ; Xiaoman AI ; Yunsong YU ; Jie LIN ; Wenxiang HUANG ; Bei JIA ; Yunzhuo CHU ; Sufei TIAN ; Yanqiu HAN ; Sufang GUO
Chinese Journal of Infection and Chemotherapy 2016;16(3):267-274
Objective To evaluate the changing pattern of antibiotic resistance inKlebsiella strains isolated from the patients in 19 hospitals across China based on the data from CHINET Antimicrobial Resistance Surveillance Program during the period from 2005 through 2014.Methods Kirby-Bauer disk diffusion and automated susceptibility testing methods were used to test the susceptibility ofKlebsiella isolates to the commonly used antibiotics. The results were interpreted according to the criteria of the Clinical and Laboratory Standards Institute (CLSI) Performance Standards for Antimicrobial Susceptibility Testing (CLSI-2014).Results A total of 61 406Klebsiella strains were identified between 2005 and 2014, includingK. pneumoniae (56 281 strains), K. oxytoca(4 779),Klebsiella pneumoniae subsp.Ozaenae (300) and otherKlebsiella species (46). Most (89.0%, 54 664/61 406) of theKlebsiella strains were isolated from inpatients, and 60.0% (36 835/61 406) were from respiratory tract speciems. About 16.7% (10 248/61 406) of the strains were isolated from pediatric patients aged 0-17 years and 83.3% (51 158/61 406) from adult patients. The prevalence ofKlebsiella spp. increased with time from 10.1% in 2005 to 14.3% in 2014. Based on the surveillance data during the 10-year period, we found a marked increase of resistance to imipenem (2.9% to 10.5%) and meropenem (2.8% to 13.4%) inKlebsiella spp. The prevalence of ESBLs-producing isolates inK. pneumoniae andK. oxytoca decreased from 39.0% in 2005 to 30.1% in 2014. The resistance to amikacin, ceftazidime, ciprolfoxacin, pipracillin-tazobactam and cefoperazone-sulbactam was on decline. The resistance rate to cefotaxime remained high about 49.5%. Carbapenem resistantance was identiifed in 5 796 (9.4%) of the isolates, including 5 492 strains ofK. pneumoniae and 280 strains ofK. oxytoca. Overall, 4 740 (7.8%) strains were identiifed as extensively-drug resistant (XDR), including 4 520 strains ofK. pneumoniae and 202 strains ofK. oxytoca. The carbapenem-resistant strains showed high (>60%) resistance rate to majority of the antimicrobial agents tested, but relatively low resistance to tigecycline (16.8%), amikacin (54.4%), and trimethoprim-sulfamethoxazole (55.5%).Conclusions During the 10-year period from 2005 through 2014, carbapenem resistance amongKlebsiella isolates has increased dramatically in the hospitals across China. The level of resistance to other antibiotics remains stable.
9.CHINET 2013 surveillance of bacterial resistance in China
Fupin HU ; Demei ZHU ; Fu WANG ; Xiaofei JIANG ; Ziyong SUN ; Zhongju CHEN ; Zhidong HU ; Jin LI ; Yi XIE ; Mei KANG ; Yingchun XU ; Xiaojiang ZHANG ; Zhaoxia ZHANG ; Ping JI ; Chuanqing WANG ; Aimin WANG ; Yuxing NI ; Jingyong SUN ; Yunsong YU ; Jie LIN ; Yunzhuo CHU ; Sufei TIAN ; Yuanhong XU ; Jilu SHEN ; Bin SHAN ; Yan DU ; Chao ZHUO ; Danhong SU ; Hong ZHANG ; Jing KONG ; Lianhua WEI ; Ling WU ; Yunjian HU ; Xiaoman AI
Chinese Journal of Infection and Chemotherapy 2014;(5):365-374
Objective To investigate the susceptibility and resistance of clinical isolates collected from hospitals in several regions of China . Methods Fourteen general hospitals and two children ’ s hospitals were involved in this program . Antimicrobial susceptibility testing was carried out according to a unified protocol using Kirby-Bauer method or automated Systems .Results were analyzed according to CLSI 2013 breakpoints .Results A total of 84 572 clinical isolates were collected from January to December 2013 ,of which gram negative organisms and gram positive cocci accounted for 73 .0% and 27 .0%respectively .Methicillin-resistant strains in S .aureus (MRSA) and coagulase negative Staphylococcus (MRCNS) accounted for an average of 45 .2% and 73 .5% respectively .The resistance rates of methicillin-resistant strains to β-lactams and other antimicrobial agents were much higher than those of methicillin-susceptible strains .However ,92 .2% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole while 87 .4% of MRCNS strains were susceptible to rifampin . No staphylococcal strains were found resistant to vancomycin ,teicoplanin or linezolid .In Enterococcus spp .,the resistance rates of E . f aecalis strains to most tested drugs (except chloramphenicol) were much lower than those of E . f aecium .Some strains of both species were resistant to vancomycin .Vancomycin-resistant strains of E . f aecalis and E . f aecium were mainly VanA type based on their phenotype .Regarding non-meningitis S . pneumoniae strains ,the prevalence of penicillin-susceptible S . pneumoniae and penicillin-intermediate S . pneumoniae strains isolated from both adults and children were lower than those isolated in 2012 ,but the prevalence of penicillin-resistant S .pneumoniae strains increased .The prevalence of ESBLs producing strains was 54 .0% in E .coli ,31 .8% in Klebsiella spp .(K .pneumoniae and K .oxytoca) and 16 .5% in Proteus mirabilis isolates on average . ESBLs-producing Enterobacteriaceae strains were more resistant than non-ESBLs-producing strains in terms of antibiotic resistance rates .The strains of Enterobacteriaceae were still highly susceptible to carbapenems .Overall less than 7 .0% of these strains were resistant to carbapenems .About 62 .8% and 59 .4% of Acinetobacter spp .(A .baumannii accounts for 89 .2% ) strains were resistant to imipenem and meropenem ,respectively .Compared with the data of year 2012 , extensively-drug resistant strains in K . pneumoniae and A . baumannii decreased .Conclusions The antibiotic resistance of clinical bacterial isolates is growing in 2013 .The disseminated multi-drug or pan-drug resistant strains in a special region poses a serious threat to clinical practice and implies the importance of strengthening infection control .
10.Antimicrobial resistance profile of clinical isolates in hospitals across China: report from the CHINET Surveillance Program, 2017
Fupin HU ; Yan GUO ; Demei ZHU ; Fu WANG ; Xiaofei JIANG ; Yingchun XU ; Xiaojiang ZHANG ; Zhaoxia ZHANG ; Ping JI ; Yi XIE ; Mei KANG ; Chuanqing WANG ; Aimin WANG ; Yuanhong XU ; Jilu SHEN ; Ziyong SUN ; Zhongju CHEN ; Yuxing NI ; Jingyong SUN ; Yunzhuo CHU ; Sufei TIAN ; Zhidong HU ; Jin LI ; Yunsong YU ; Jie LIN ; Bin SHAN ; Yan DU ; Sufang GUO ; Lianhua WEI ; Fengmei ZOU ; Hong ZHANG ; Chun WANG ; Yunjian HU ; Xiaoman AI ; Chao ZHUO ; Danhong SU ; Ruizhong WANG ; Hua FANG ; Bixia YU ; Yong ZHAO ; Ping GONG ; Dawen GUO ; Jinying ZHAO ; Wenen LIU ; Yanming LI ; Yan JIN ; Chunhong SHAO ; Kaizhen WEN ; Yirong ZHANG ; Xuesong XU ; Chao YAN ; Hua YU ; Xiangning HUANG ; Shanmei WANG ; Yafei CHU ; Lixia ZHANG ; Juan MA ; Shuping ZHOU ; Yan ZHOU ; Lei ZHU ; Jinhua MENG ; Fang DONG ; Hongyan ZHENG ; Han SHEN ; Wanqing ZHOU ; Wei JIA ; Gang LI ; Jinsong WU ; Yuemei LU
Chinese Journal of Infection and Chemotherapy 2018;18(3):241-251
Objective To investigate the antimicrobial resistance profile of the clinical isolates collected from selected hospitals across China. Methods Twenty-nine general hospitals and five children's hospitals were involved in this program. Antimicrobial susceptibility testing was carried out according to a unified protocol using Kirby-Bauer method or automated systems. Results were interpreted according to CLSI 2017 breakpoints. Results A total of 190 610 clinical isolates were collected from January to December 2017, of which gram negative organisms accounted for 70.8% (134 951/190 610) and gram positive cocci 29.2% (55 649/190 610). The prevalence of methicillin-resistant strains was 35.3% in S. aureus (MRSA) and 80.3% in coagulase negative Staphylococcus (MRCNS) on average. MR strains showed much higher resistance rates to most of the other antimicrobial agents than MS strains. However, 91.6% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 86.2% of MRCNS strains were susceptible to rifampin. No staphylococcal strains were found resistant to vancomycin. E. faecalis strains showed much lower resistance rates to most of the drugs tested (except chloramphenicol) than E. faecium. Vancomycin-resistant Enterococcus (VRE) was identified in both E. faecalis and E. faecium. The identified VRE strains were mainly vanA, vanB or vanM type based on phenotype or genotype. The proportion of PSSP or PRSP strains in the non-meningitis S.pneumoniae strains isolated from children decreased but the proportion of PISP strains increased when compared to the data of 2016. Enterobacteriaceae strains were still highly susceptible to carbapenems. Overall, less than 10% of these strains (excluding Klebsiella spp.) were resistant to carbapenems. The prevalence of imipenem-resistant K. pneumoniae increased from 3.0% in 2005 to 20.9% in 2017, and meropenem-resistant K. pneumoniae increased from 2.9% in 2005 to 24.0% in 2017, more than 8-fold increase. About 66.7% and 69.3% of Acinetobacter (A. baumannii accounts for 91.5%) strains were resistant to imipenem and meropenem, respectively. Compared with the data of year 2016, P. aeruginosa strains showed decreasing resistance rate to carbapenems. Conclusions Bacterial resistance is still on the rise. It is necessary to strengthen hospital infection control and stewardship of antimicrobial agents. The communication between laboratorians and clinicians should be further improved in addition to surveillance of bacterial resistance.