Bacterial carbapenem resistance is a major public health concern since these antimicrobials are often the last resort to treat serious human infections. To evaluate methodologies for detection of carbapenem resistance, carbapenem-tolerant bacteria were isolated from wastewater treatment plants in Toronto, Ottawa, and Arnprior, Ontario. A total of 135 carbapenem-tolerant bacteria were recovered. Polymerase chain reaction (PCR) indicated the presence of carbapenem hydrolysing enzymes KPC ( n = 10), GES ( n = 5), VIM ( n = 7), and IMP ( n = 1), and β-lactamases TEM ( n = 7), PER ( n = 1), and OXA-variants ( n = 16). A subset of 46 isolates were sequenced and analysed using ResFinder and CARD-RGI. Both programs detected carbapenem resistance genes in 35 sequenced isolates and antimicrobial resistance genes (ARGs) conferring resistance to multiple class of other antibiotics. Where β-lactamase resistance genes were not initially identified, lowering the thresholds for ARG detection enabled identification of closely related β-lactamases. However, no known carbapenem resistance genes were found in seven sequenced Pseudomonas spp. isolates. Also of note was a multi-drug-resistant Klebsiella pneumoniae isolate from Ottawa, which harboured resistance to seven antimicrobial classes including β-lactams. These results highlight the diversity of genes encoding carbapenem resistance in Ontario and the utility of whole genome sequencing over PCR for ARG detection where resistance may result from an assortment of genes.
-The arrival on the hospital ward of a person who was fabricating an illness was an unsettling experience for the medical and nursing staff involved. As the patient was expected only to be present for a short time and claimed to have a proven diagnosis, the approach may have been less rigorous than usual. The article describes the experience of three members of staff with a patient who proved to have Munchausen's syndrome, and their reaction to discovering the truth. KEY WORDS: fictitious illness, Munchausen's syndrome Dr Crawford writes:Recently a patient was admitted to our oncology ward as an emergency. After he had spent four nights in the hospital I found myself asking him to leave.Munchausen's syndrome has fascinated me ever since I read Richard Asher's original report 1 and the account by Pallis and Bandjee in the BMJ, 'McIllroy was here. Or was he?' . 2 Actually to encounter a person with Munchausen's syndrome is a most unsettling experience.A man who gave his age as 33 attended the hospital complaining of severe pain, nausea and vomiting. According to the history he gave, he had HIV-related Kaposi's sarcoma and had recently had chemotherapy with doxorubicin and radiotherapy in a London teaching hospital. He mentioned in passing that his consultant oncologist had just gone away on holiday. He was taking slow release morphine sulphate tablets 50 mg bd. He claimed he was visiting his parents who lived in our locality.The specialist registrar covering acute medicine on that day admitted him and discussed him with me and I saw him on my routine ward round on the Sunday morning. On his arrival on the admissions ward he had received a couple of doses of morphine subcutaneously, and we adjusted this to oral morphine given four hourly and discussed the principles of dose titration with him. He received metoclopramide and then cyclizine as anti-emetics. He complained that the pain was only slightly relieved by the analgesics that we were using, so we increased the dose of morphine. He was also written up for the anti-retroviral drugs he said he was taking regularly,
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