Carbapenem-resistant *Klebsiella pneumoniae*, *Escherichia coli*, and *Acinetobacter baumannii* are spreading through Chinese hospitals, and this project will track exactly how they move between patients, staff, and the wider community. These bacteria are resistant to carbapenems, the last-resort antibiotics for multi-drug resistant infections. While genomic surveillance has helped Western hospitals identify outbreaks and cut transmission routes, China lacks this fine-scale data. The national CHINET network reports that these three species are the most common bacteria recovered from clinical samples, and their carbapenem resistance is rising sharply. Without genomic-level investigation, hospitals cannot distinguish between a single imported case and an ongoing ward-to-ward outbreak. The research will run three parallel projects: one tracking *K. pneumoniae* transmission within hospitals, one examining how *E. coli* enters hospitals from the community, and one mapping *A. baumannii* reservoirs. Success would give Chinese infection control teams the same real-time outbreak detection and source-tracing tools already used in the West. The immediate impact is practical: fewer hospital-acquired infections, shorter patient stays, and preserved use of last-line antibiotics.
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Modern genomic technologies and development of genome analysis tools have been successfully applied to improve our understanding of the emergence, spread, short term evolution, and transmission of clinically important MDR bacteria. Genomic analysis has allowed us to determine with fine scale resolution the role played by inter-hospital patient transfer in national and international dissemination of MDR pathogens. It has allowed us to determine the selective forces which drive the evolution of MDR pathogens in the hospital and within patients and the clinical impact this can impose. Genomic analysis has also been used to identify outbreaks, potential sources of outbreaks, and inform successful interventions to bring an end to outbreaks within hospitals. The scale of the MDR problem in Chinese hospitals is reaching alarming levels. The incidence of morbidity and mortality associated with MDR infections in China has grown year-on-year in the 21st century. Most alarming is the rise in the incidence of infections caused by A. baumannii, E. coli and K. pneumoniae which are resistant to carbapenems, that last line of antibiotics available to treat infections with MDR pathogens. The national CHINET network of clinical microbiology laboratories of 34 sentinel hospitals across China (www.chinets.com) report that in 2017, E. coli, K. pneumoniae and A. baumannii were the top three bacterial species recovered from clinical samples. There were 13,337 known cases of carbapenem resistant A. baumannii (69.3% carbapenem resistance prevalence), 6,434 cases of carbapenem resistant K. pneuomoniae (23% carbapenem resistance prevalence), and 845 cases of carbapenem resistant E. coli (2.3% carbapenem resistance prevalence). It is therefore vital that genomic level investigations of these bacteria are implemented in China immediately, to allow the breakthroughs in understanding transmission, spread, and infection control that have been afforded in the Western world. The proposed research to be conducted by the network will be organised around three independent but inter-connected projects: 1) Investigate the reservoirs and routes of transmission of carbapenem resistant K. pneumoniae 2) Investigate the community carriage dynamics of carbapenem resistant E. coli leading to the continuous introduction of strains into hospitals and subsequent infections. 3) Investigate the reservoirs and routes of transmission of carbapenem resistant Acinetobacter baumannii.
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