碳青霉烯类耐药肺炎克雷伯菌基因型检测研究

目的 分析碳青霉烯类耐药肺炎克雷伯菌(CRKP)不同基因型耐药性及临床特征差异，为临床预防及治疗CRKP感染提供参考。方法 回顾性分析我院2018年9月—2021年8月收治的56例分离出CRKP菌株患者的临床资料，检测其耐药基因，并分析不同基因型CRKP的耐药性和临床特征。结果 56株CRKP中检出47株KPC型耐药基因(83.93%)、9株NDM-1型耐药基因(16.07%),未检出IMP、VIM以及OXA-48耐药基因；耐药性分析结果发现，KPC和NMD-1型耐药基因对氨曲南耐药性差异有统计学意义(P<0.05);KPC和NMD-1型耐药基因对应患者年龄、性别、收治科室、标本来源分布情况、合并基础疾病、抗菌药物使用时间、3种及以上抗菌药物联用史、住院时间以及侵入性操作比较差异均无统计学意义(P>0.05)。结论 CRKP基因型主要以KPC型最常见，不同基因型CRKP临床特征无明显差异，不同基因型CRKP对常用抗菌药物耐药性存在异质性，临床抗感染治疗需结合基因检测及耐药性分析制定合理方案。     

住院患者血流感染革兰阴性菌分布特征和耐药性及耐药菌株碳青霉烯酶基因检测

目的检测和分析住院患者血流感染的革兰阴性菌分布特征、耐药性及耐药菌株碳青霉烯酶基因携带情况。方法选择2017年1月-2019年12月住院的血流感染患者186例,检测感染革兰阴性菌分布特征,通过药敏试验检测主要革兰阴性菌的耐药情况,PCR检测耐碳青霉烯类菌株碳青霉烯酶基因携带情况。结果 186例血流感染患者血液标本中分离出革兰阴性菌106株,其中肺炎克雷伯菌占28.30%(30/106)、大肠埃希菌占26.42%(28/106)、不动杆菌占14.15%(15/106)、铜绿假单胞菌占9.43%(10/106)、肠杆菌占7.55%(8/106)、其他细菌占14.15%(15/106);药敏试验检测肺炎克雷伯菌对阿米卡星、头孢哌酮-舒巴坦钠、哌拉西林-他唑巴坦、甲氧苄啶-磺胺甲恶唑以及厄他培南、亚胺培南、美罗培南耐药率低于50.0%,大肠埃希菌对阿米卡星、头孢哌酮-舒巴坦钠、哌拉西林-他唑巴坦以及厄他培南耐药率低于50.0%,不动杆菌对多种抗菌药物的耐药率高于50.0%,铜绿假单胞菌、肠杆菌对多种抗菌药物的耐药率低于50.0%;25株耐碳青霉烯类菌株中有19株检出碳青霉烯酶基因,KPC、OXA23、OXA51和NDM基因检出率分别为44.0%(11/25)、32.0%(8/25)、28.0%(7/25)和4.0%(1/25)。结论革兰阴性菌为住院患者血流感染的主要致病菌,耐药菌有集中于肺炎克雷伯菌和不动杆菌的趋势,携带KPC和OXA23基因可能是耐药菌耐碳青霉烯类的主要机制。     

老年患者感染鲍曼不动杆菌耐药性变迁机制

目的通过分析鲍曼不动杆菌的感染特征、耐药性及其产碳青霉烯酶的类型,探讨其对亚胺培南类抗生素的耐药机制。方法收集该院对碳青霉烯类药物敏感、中介或耐药的鲍曼不动杆菌株162株,用琼脂纸片扩散法(K-B法)及肉汤稀释法测定最低抑菌浓度(MIC),用聚合酶链反应(PCR)检测其耐药基因。结果 60株耐药细菌均为多重耐药株,PCR检出47株携带OXA-23基因,3株携带OXA-24基因,85株敏感株均未检出OXA-23及OXA-24基因,各年份与2008年对亚胺培南类药物敏感性以及耐药基因OXA-23基因携带率比较有统计学差异(P0.05)。结论携带OXA-23和OXA-24碳青霉烯酶基因的鲍曼不动杆菌对临床常用亚胺培南类抗生素的耐药率明显增高,且伴随用药时间延长呈逐年上升趋势。     

江苏省昆山地区耐亚胺培南鲍曼不动杆菌的耐药性及碳青霉烯酶基因型分析

目的调查江苏省昆山地区耐亚胺培南鲍曼不动杆菌（CRAB）的耐药性及碳青霉烯酶基因型,为临床防治此类感染提供依据。方法收集昆山市中医医院患者分离的70株CRAB,采用纸片扩散法进行药敏试验,采用亚胺培南-EDTA纸片增效法和改良Hodge试验进行金属酶及碳青霉烯酶表型初筛;用6种碳青霉烯酶特异性基因引物进行PCR扩增和基因型的测序分析,并通过网上GenBank进行比对以确定编码酶基因的类型。结果70株CRAB对头孢哌酮／舒巴坦和阿米卡星的耐药率分别为61．4％和70％,对其他11种常用抗菌药物的耐药率均〉80％;检出金属酶耐药表型10株、碳青霉烯酶耐药表型68株,PCR扩增出OXA-51基因型70株、IMP-1基因型8株、OXA-23基因型66株,OXA-24、OXA-58及VIM-1基因扩增结果均为阴性。结论本地区CRAB耐药现象严重,临床应加强监测并根据药敏结果合理使用抗菌药物;OXA-51、OXA-23及金属酶基因IMP．1在介导本地区鲍曼不动杆菌对碳青霉烯类抗菌药物耐药中起重要作用。     

114株耐碳氢酶烯肺炎克雷伯杆菌耐药表型及基因分析

目的:分析114株耐碳氢酶烯肺炎克雷伯杆菌（CRKP）的耐药表型与基因型,为控制耐碳氢酶烯肺炎克雷伯杆菌传播及临床治疗提供依据。方法： 选取住院患者痰样本分离的114株CRKP,采用VITECK2全自动细菌鉴定仪进行菌种鉴定并验证其对碳青霉烯的药敏性。采用改良碳青霉烯灭活法（mCIM法）检测CRKP的耐药表型;采用PCR法检测碳氢酶烯酶blaKPC、blaNDM、blaIMP、blaVIM、blaOXA 4耐药基因。结果： 114株CRKP经mCIM法检测阳性率为95.61%,耐药表型均为KPC型。耐药菌对青霉素类、头孢菌素类和碳青霉烯类药物的耐药率均在95%~100%;对氨基糖苷类、喹诺酮类、四环素类和氯霉素类药物的耐药率分别为70%~75%、82%~87%、90%~95%和80%~84%（均P<0.05）。经PCR检测,blaKPC基因阳性检出率为100%。脉冲凝胶电泳（PFGE）分子分型共分为13个谱型,优势型别为KPN01.005型（35株）,各菌株间相似性系数达92.0％以上。结论：宁乡市人民医院CRKP的耐药十分严重,与其携带blaKPC耐药基因密切相关。应加强细菌耐药性监测和医院感染的监控。     

碳青霉烯酶药物不敏感的肠杆科细菌中KPC酶的检测及分析

目的 了解海南地区三级医院中肠杆菌科细菌产KPC酶的流行状况及型别特点。方法 收集2012年8月到2013年6月海南地区四家三级医院无菌部位分离的对亚胺培南或厄他培南中介或耐药的肠杆菌科细菌43株,运用改良Hodge试验进行KPC表型筛查;PCR的方法进行基因型别检测。结果 43株细菌中,21株改良Hodge试验阳性;PCR检测3株为阳性,基因测序比对分析均为KPC-2型。结论 海南地区对碳青霉烯酶类药物不敏感的肠杆科细菌中KPC酶的主要基因型别KPC-2型,携带KPC酶的质粒可在不同种属细菌间水平传递,临床应加强监控,防止产碳青霉烯酶菌株在医院环境中暴发和流行。     

呼吸机相关性肺炎患者耐碳青霉烯类肺炎克雷伯菌病原菌分析及耐药性监测

目的分析ICU呼吸机相关性肺炎患者耐碳青霉烯类肺炎克雷伯菌(CRKP)感染的临床危险因素,并监测其耐药性,为CRKP感染的防控和治疗提供依据。方法收集我院2017年3月-2019年3月重症医学科发生肺炎克雷伯菌感染肺炎的患者共64例,其中23例患者感染耐碳青霉烯类肺炎克雷伯菌(CRKP组),41例对碳青霉烯类抗菌药物敏感的肺炎克雷伯菌感染患者(CSKP组),分析两组患者基本情况、检出CRKP情况、CRKP携带的耐药基因及ST型情况,并行耐药性分析。结果有慢性肺病、机械通气时间≥7 d、感染前使用抗菌药物≥7 d、使用抗菌药物种类2种,以及使用过碳青霉烯类抗生素的患者检出CRKP概率更高;CRKP检出耐药基因有KPC-2(100%)、CTX-M-24(95.65%)、ompk35(95.65%)、ompk36(91.30%)、SHV-12(82.61%)、TEM-1(86.96%),NDM-1(8.70%), ST11型菌株所占78.26%,ST23型8.70%、ST25型8.70%,ST37型4.35%;CRKP对哌拉西林/他唑巴坦、头孢他啶、头孢曲松耐药性达100.00%,对替加环素4.35%、四环素8.70%、复方新诺明13.04%。结论 CRKP危险因素、耐药基因和种类较多,临床应针对可能的危险因素和耐药情况,采取相对应预防和治疗,从而预防与减少CRKP感染发生。     

82株肺炎克雷伯菌β-内酰胺耐药性与基因型相关性分析

目的检测82株肺炎克雷伯菌β-内酰胺类抗生素耐药性,分析其与16种β-内酰胺酶基因的相关性。方法临床分离的肺炎克雷伯菌(KPN)82株,采用自动细菌检定系统检测其对18种常用β-内酰胺类抗生素的耐药性和16种β-内酰胺酶基因携带情况,并分析细菌耐药性与β-内酰胺酶基因型的相关性。结果临床分离株KPN对SCF耐药较高,为94.1%;对MPM的耐药率较低,为24.2%。82株KPN共检出SHV、TEM-1、KPC-2、NDM-1、OXA-1、OXA-2、CTX-M-3、CTX-M-14、CTX-M-15、CMY-4等10种β-内酰胺酶基因,其中前4种阳性率分别为100%、100%、7.3%和2.5%;碳青酶烯耐药株和碳青酶烯敏感株OXA-1、CMY-4、KPC-2及NDM-1基因阳性率分别为11.0%~100.0%,差异有统计学意义(P0.05);基因型E型(SHV+TEM+CTX-M群+OXA群)较常见,检出率为48.8%,与药敏型Ⅷ型相符度(以药敏型为标准)为75%;基因型D型KPN中,药敏型Ⅰ型和Ⅱ型所占比例较高,达61.9%。结论长沙地区临床分离株KPNβ-内酰胺类抗生素耐药情况严重,β-内酰胺类耐药基因的携带也表现为多样化,其中SHV、TEM基因携带率高达100%,携带OXA-1、CMY-4、KPC-2及NDM-1的KPN更有可能对碳青霉烯类抗生素耐药,基因型为D型的KPN更有可能对非碳青霉烯β-内酰胺类抗生素耐药。     

鲍曼不动杆菌耐药分析及碳青霉烯酶检测

目的分析我院鲍曼不动杆菌耐药情况及碳青霉烯类抗生素耐药鲍曼不动杆菌(CRAB)耐药机制,调查感染因素,为治疗及控制院感提供依据。方法回顾分析我院2001-2011年检出的1571株鲍曼不动杆菌耐药情况;检测40株CRAB碳青霉烯酶基因型;与40位患者接触的医务人员手、环境物体消毒监测。结果鲍曼不动杆菌主要来自痰液占50.9%,临床分布以烧伤科为主占37.4%,对多种抗生素耐药。35株CRAB检出OXA-23。医护人员手、呼吸、神经外科和泌尿外科环境≤10cfu/cm2,烧伤科、ICU≤5cfu/cm2。结论我院鲍曼不动杆菌耐药情况严重,CRAB耐药机制是OXA-23,感染因素是抗生素选择性压力。     

耐碳青霉烯类肺炎克雷伯菌在医院获得性肺炎中的流行病学与耐药性分析

目的探讨耐碳青霉烯类肺炎克雷伯菌(CRKP)在医院获得性肺炎(HAP)中的流行病学与耐药性,为临床用药治疗与耐药性预防提供依据。方法对2012-2018年本院发生HAP感染的患者进行病原谱与耐药性分析,并筛选出62例CRKP感染患者为CRKP组,另随机选取156例碳青霉烯类敏感的肺炎克雷伯菌(CSKP)感染患者为CSKP组,进行流行病学、细菌耐药性及感染因素分析。结果 HAP患者感染前5位的病原菌依次为铜绿假单胞菌、鲍曼不动杆菌、大肠埃希菌、肺炎克雷伯菌和金黄色葡萄球菌,其中铜绿假单胞菌、鲍曼不动杆菌感染发生率逐年下降;肺炎克雷伯菌感染发生率逐年升高,从2012年的7.83%上升至2018年的15.3%。肺炎克雷伯菌除对阿米卡星、庆大霉素与妥布霉素以外的各类抗菌药物的敏感性均呈现出逐年下降的趋势,尤其对于碳青霉烯类抗菌药物亚胺培南与厄他培南,敏感率分别从2012年的97.7%和98.9%下降至2018年的62.1%和64.2%;CRKP对阿米卡星、庆大霉素和妥布霉素的耐药率稍低,分别为71.0%、77.4%和74.2%,对其他抗菌药物耐药率均较高。单因素分析显示,住院时间≥2周、实行气管插管或气管切开术、病菌感染≥3种、抗菌药物使用≥2周、使用抗菌药物≥3种以及使用碳青霉烯类等与CRKP感染显著相关(P0.05);多因素分析显示,住院时间≥2周(P=0.031)、使用碳青霉烯类(P=0.006)、实行气管插管或气管切开术(P=0.008)是CRKP感染的独立危险因素(P0.05)。结论耐碳青霉烯类肺炎克雷伯菌(CRKP)在HAP患者感染率逐年上升,且多为泛耐药菌株,临床应加强对CRKP的监测并合理使用抗生素。住院时间≥2周、使用碳青霉烯类、接受气管插管或气管切开术是引起CRKP感染的独立危险因素,因此应制定相关干预措施预防和控制CRKP的感染、播散和流行。     

耐碳青霉烯肺炎克雷伯菌感染的危险因素及耐药机制的研究

目的 探讨耐碳青霉烯肺炎克雷伯菌感染的危险因素及耐药机制.方法 对我院2018年6月1日-2019年5月31日57例耐碳青霉烯肺炎克雷伯菌(CRKP)感染患者和70例碳青霉烯敏感肺炎克雷伯菌(CSKP)感染患者进行回顾性分析.结果 CRKP感染患者主要分布在呼吸科31.6％(18/57)、神经内科21.1％(12/57...     

血培养中碳青霉烯类耐药鲍曼不动杆菌感染特征及耐药基因分析

目的 分析我院2018—2020年临床血培养检出的碳青霉烯类耐药鲍曼不动杆菌(carbapenem-resistant Acinetobacter Baumannii, CRAB)的感染特征及耐药基因分布情况,为防止院内感染、临床抗菌药物的合理使用及临床早期经验性提供依据。方法 收集2018年1月至2020年12月临床分离的血培养鲍曼不动杆菌48株,应用Logistic回归分析血流感染CRAB的可能危险因素。采用VITEK2 Compact全自动微生物分析系统进行细菌鉴定及药敏试验,热裂解法提取DNA,并应用PCR的方法检测常见鲍曼不动杆菌的碳青霉烯类耐药基因(OXA-23、OXA-51、NDM-1)及插入序列ISAba-1、整合酶Int I基因。结果 在所有XDR-AB中重症医学科的检出率最高,占68.4%。Logistic回归分析结果显示,肺炎、恶性肿瘤、静脉穿刺置管、输血、气管插管、尿管插管、胃管插管及支气管镜检查与血流感染CRAB有关(P<0.05),且肺炎(OR=81.894)是血流感染CRAB的独立危险因素(χ²=4.689,P<0.05)。多重耐药菌(13株)和广泛耐药菌(19株)均携带有OXA-23与OXA-51基因。敏感菌株中OXA-51基因检出率为43.8%,没有检测出OXA-23基因。48株菌株均没有检测出NDM-1基因。耐药基因OXA-23、OXA-51、ISAba-1的检出率在耐药菌和敏感菌之间差异有统计学意义(χOXA-232=48.000,χOXA-512=13.066,χISAba-12=15.709,均P<0.05)。结论 肺炎为我院血流感染CRAB的独立危险因素,非恶性肿瘤的患者感染CRAB的风险是有恶性肿瘤患者的21倍。本院碳青霉烯类耐药鲍曼不动杆菌主要为OXA-23型与OXA-51型菌株,且携带有OXA-23耐药基因的鲍曼不动杆菌对碳青霉烯类药物耐药率为100%,未携带该耐药基因的鲍曼不动杆菌对该类药物均呈敏感,提示OXA-23基因可能是造成CRAB耐药的原因,临床应加强院感管理,合理使用抗菌药物,防止该类鲍曼不动杆菌的暴发传播。     

Investigation of carbapenem resistance and the first identification of Klebsiella pneumoniae carbapenemase (KPC) enzyme among Escherichia coli isolates in Turkey: A prospective study

BackgroundThe aim of this study was to determine the presence of carbapenem resistance and carbapenemase production in Escherichia coli isolates from clinical samples in Turkey.MethodsThe prospective study included a total of 4.052 Escherichia coli isolates collected from patients admitted to a hospital from March 2011 to May 2012. We used ertapenem disc for screening carbapenemase production, and the confirmation was performed by using Etest. The resistance mechanisms and genetic relatedness of the carbapenem resistant strains were investigated by using PCR (polymerase chain reaction) and pulsed-field gel electrophoresis (PFGE), respectively.ResultsAmong the 4.052 E. coli isolates, 24 (0.59%) were found to be carbapenem resistant. Of these, only 5 isolates were positive for OXA-48 and 2 isolates were positive for Klebsiella pneumoniae carbapenemase (KPC)-2. The KPC-2 producing E. coli strains (n = 2) were both isolated from the same patient. The bla_KPC genes were confirmed using DNA sequence analysis. The genetic relationship between the 24 E. coli strains studied by PFGE revealed that the strains were genetically unrelated.ConclusionsThis article confirms, to our knowledge for the first time, the detection of KPC-2-producing E. coli in Turkey, with OXA-48 being the most frequent carbapenemase in the study.     

Bloodstream infections caused by Klebsiella pneumoniae in onco‐hematological patients: clinical impact of carbapenem resistance in a multicentre prospective survey

The aim of this study was to identify risk factors for mortality in patients suffering from hematological malignancies (HMs) with bloodstream infections (BSIs) caused by Klebsiella pneumoniae (KP). We conducted a prospective cohort study on KP BSI in 13 Italian hematological units participating in the HEMABIS registry–SEIFEM group. The outcome measured was death within 21 days of BSI onset. Survivor and non‐survivor subgroups were compared and Cox regression analysis was conducted to identify independent predictors of mortality. A total of 278 episodes of KP BSI were included in the study between January 2010 and June 2014. We found that 161 (57.9%) KP isolates were carbapenem resistant (CRKP). The overall 21‐day mortality rate was 36.3%. It was significantly higher for patients with CRKP BSI (84/161, 52.2%) than for those with BSI caused by carbapenem susceptible KP (CSKP) (17/117, 14.5%; P < 0.001). Septic shock (HR 3.86), acute respiratory failure (HR 2.32), inadequate initial antimicrobial therapy (HR 1.87) and carbapenem resistance by KP isolates (HR 1.85) were independently associated with mortality. A subanalysis was conducted in only 149 patients with CRKP BSI who had received ≥48 hr of adequate antibiotic therapy, and combination therapy was independently associated with survival (HR 0.32). Our study shows that in recent years carbapenem resistance has dramatically increased in HM patients with KP BSI in Italy and is associated with a worse outcome. The optimal management of such infections and the definition of new empirical/targeted antimicrobial strategies in HM patients can still be considered unmet clinical needs. Am. J. Hematol. 91:1076–1081, 2016. © 2016 Wiley Periodicals, Inc.     

梅州地区临床分离耐碳氢霉烯类鲍曼不动杆菌的耐药机制及分子流行病学研究

目的 了解梅州地区临床分离的耐碳青霉烯类鲍曼不动杆菌的耐药性,探讨其耐药机制及分子流行病学特征。方法 收集梅州地区5所医院2012年1～12月临床分离的非重复耐碳青霉烯类鲍曼不动杆菌210株,采用K-B法检测药敏性,改良Hodge试验筛选耐碳青霉烯表型,PCR扩增IMP、VIM、OXA-23、OXA-24、OXA-51和OXA-58型碳氢霉烯酶基因,并测序。应用ERIC-PCR分型及同源性分析。结果 药敏结果显示,17种药物除多粘菌素B耐药率为0.48%外,其他药敏耐药率都高于60%;改良Hodge试验阳性菌株163株(77.62%)。扩增结果显示Bla-OXA-51的检出率为最高为94.29%(198/210),Bla-OXA-23的检出率次之为78.57%(165/210),Bla-VIM的检出率为4.29%(9/210),Bla-IMP、Bla-OXA-24、Bla-OXA-58均未被检出。210株菌株分为7个ERIC基因型,其中A型97株,B型44株,H型25株,为主要的流行克隆株。结论 梅州地区临床分离的耐碳青霉烯类鲍曼不动杆菌耐药十分严重;产OXA-51、OXA-23和VIM型碳氢霉烯酶是本地区鲍曼不动杆菌对碳青霉烯类药物耐药的重要机制,且耐碳青霉烯类鲍曼不动杆菌存在克隆的流行。     

Crystal structure of the carbapenemase OXA-24 reveals insights into the mechanism of carbapenem hydrolysis

Combating bacterial resistance to beta-lactams, the most widely used antibiotics, is an emergent and clinically important challenge. OXA-24 is a class D beta-lactamase isolated from a multiresistant epidemic clinical strain of Acinetobacter baumannii. We have investigated how OXA-24 specifically hydrolyzes the last resort carbapenem antibiotic, and we have determined the crystal structure of OXA-24 at a resolution of 2.5 A. The structure shows that the carbapenem's substrate specificity is determined by a hydrophobic barrier that is established through the specific arrangement of the Tyr-112 and Met-223 side chains, which define a tunnel-like entrance to the active site. The importance of these residues was further confirmed by mutagenesis studies. Biochemical and microbiological analyses of specific point mutants selected on the basis of structural criteria significantly reduced the catalytic efficiency (k(cat)/K(m)) against carbapenems, whereas the specificity for oxacillin was noticeably increased. This is the previously unrecognized crystal structure that has been obtained for a class D carbapenemase enzyme. Accordingly, this information may help to improve the development of effective new drugs to combat beta-lactam resistance. More specifically, it may help to overcome carbapenem resistance in A. baumannii, probably one of the most worrying infectious threats in hospitals worldwide.     

铜绿假单胞菌耐药性分析及分子流行病学研究简

目的 分析铜绿假单胞菌（PA）耐药现状及耐药基因情况.方法收集2009~2012年临床分离的PA 305株.K-B法进行药敏试验,并检出产ESBLs菌株及耐碳青霉烯的PA,用聚合酶链反应（PCR）对产ESBLs菌株进行TEM、SHV、CTX-M基因检测,对耐碳青霉烯PA进行VIM、IPM、OXA-23基因检测.结果 3年中PA对亚胺培南、美罗培南、头孢他啶、左氧的耐药率呈上升趋势,氨曲南、阿米卡星的耐药率呈下降趋势,305株PA中共检出48株产ESBLs,57株耐碳青霉烯.PCR检测出5株PA含TEM基因,2株含SHV基因.CTX-M、VIM、IPM、OXA-23基因检测均为阴性.结论 产ESBLs是我院耐药PA的重要原因,耐碳青霉烯的PA不含VIM、IPM、OXA-23基因.     

Detection of carbapenemases and other mechanisms of enzymatic resistance to β-lactams in Enterobacteriaceae with diminished susceptibility to carbapenems in a tertiary care hospital

Introduction

Our objective was to characterize the enzymatic β-lactam resistance in clinical Enterobacteriaceae isolates with diminished susceptibility to carbapenems from 2013 to 2014 at Hospital Universitario Miguel Servet.

The proportion of general practitioner referrals to a hospital Respiratory Medicine clinic suitable to be seen in a GPwSI Respiratory Clinic.

AIMS: The purpose of this study was to examine the proportion of general practitioner (GP) referrals to a hospital Respiratory Medicine clinic which might be suitable for a General Practitioner with a Special Interest (GPwSI) Respiratory Clinic. METHOD: All GP referral letters to the Respiratory Medicine Department of a teaching hospital, apart from urgent cancer referrals, were identified from two two-week periods. All patient and practice identifications were removed. Two GPs and one Consultant Respiratory Physician assessed each of the anonymised referral letters to determine the patient's suitability to be seen in a GPwSI Respiratory Clinic, assuming such a clinic had a predetermined range of investigative facilities. RESULTS: Out of 96 referrals covering a wide range of respiratory conditions apart from lung cancer, 22 (23%) were considered by all assessors to be suitable for a GPwSI clinic, and there was full agreement that 40 referrals (42%) were unsuitable. The other 34 referrals (35%) had varying degrees of agreement on suitability. The largest groups of patient referrals considered suitable for a GPwSI clinic were those with chronic obstructive pulmonary disease (COPD) or cough as the main presenting clinical problem. The commonest groups considered unsuitable were referrals of patients with an abnormal chest radiograph, haemoptysis, or possible interstitial lung disease. CONCLUSION: This small study has shown that at least a fifth of GP referrals to a hospital Respiratory Medicine clinic could be seen in a suitably resourced GPwSI clinic, with consequent reductions in hospital outpatient waiting lists and improved accessibility for patients. This finding will be of interest to potential commissioners of GPwSI services especially with the advent of Practice-based Commissioning.