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Weimann A, Dinan AM, Ruis C, Bernut A, Pont S, Brown K, Ryan J, Santos L, Ellison L, Ukor E, Pandurangan AP, Krokowski S, Blundell TL, Welch M, Blane B, Judge K, Bousfield R, Brown N, Bryant JM, Kukavica-Ibrulj I, Rampioni G, Leoni L, Harrison PT, Peacock SJ, Thomson NR, Gauthier J, Fothergill JL, Levesque RC, Parkhill J, Floto RA. Evolution and host-specific adaptation of Pseudomonas aeruginosa. Science 2024; 385:eadi0908. [PMID: 38963857 DOI: 10.1126/science.adi0908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/02/2024] [Indexed: 07/06/2024]
Abstract
The major human bacterial pathogen Pseudomonas aeruginosa causes multidrug-resistant infections in people with underlying immunodeficiencies or structural lung diseases such as cystic fibrosis (CF). We show that a few environmental isolates, driven by horizontal gene acquisition, have become dominant epidemic clones that have sequentially emerged and spread through global transmission networks over the past 200 years. These clones demonstrate varying intrinsic propensities for infecting CF or non-CF individuals (linked to specific transcriptional changes enabling survival within macrophages); have undergone multiple rounds of convergent, host-specific adaptation; and have eventually lost their ability to transmit between different patient groups. Our findings thus explain the pathogenic evolution of P. aeruginosa and highlight the importance of global surveillance and cross-infection prevention in averting the emergence of future epidemic clones.
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Affiliation(s)
- Aaron Weimann
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for AI in Medicine, University of Cambridge, Cambridge, UK
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Adam M Dinan
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for AI in Medicine, University of Cambridge, Cambridge, UK
| | - Christopher Ruis
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for AI in Medicine, University of Cambridge, Cambridge, UK
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Audrey Bernut
- Laboratory of Pathogens and Host Immunity (LPHI), UMR5235, CNRS/Université de Montpellier, Montpellier, France
| | - Stéphane Pont
- Laboratory of Pathogens and Host Immunity (LPHI), UMR5235, CNRS/Université de Montpellier, Montpellier, France
| | - Karen Brown
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
| | - Judy Ryan
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
| | - Lúcia Santos
- Department of Physiology, Bioscience Institute, University College Cork, Cork, Ireland
| | - Louise Ellison
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
| | - Emem Ukor
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
| | - Arun P Pandurangan
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Biochemistry, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sina Krokowski
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
| | - Tom L Blundell
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Biochemistry, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Martin Welch
- Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Beth Blane
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Kim Judge
- Wellcome Sanger Institute, Hinxton, UK
| | - Rachel Bousfield
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals Trust, Cambridge, UK
| | | | | | - Irena Kukavica-Ibrulj
- Institut de Biologie Intégrative et des Systèmes (IBIS), Université Laval, Québec City, Québec, Canada
| | - Giordano Rampioni
- Department of Science, University Roma Tre, Rome, Italy
- IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Livia Leoni
- Department of Science, University Roma Tre, Rome, Italy
| | - Patrick T Harrison
- Department of Physiology, Bioscience Institute, University College Cork, Cork, Ireland
| | - Sharon J Peacock
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals Trust, Cambridge, UK
| | - Nicholas R Thomson
- Wellcome Sanger Institute, Hinxton, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeff Gauthier
- Institut de Biologie Intégrative et des Systèmes (IBIS), Université Laval, Québec City, Québec, Canada
| | - Jo L Fothergill
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Roger C Levesque
- Institut de Biologie Intégrative et des Systèmes (IBIS), Université Laval, Québec City, Québec, Canada
| | - Julian Parkhill
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - R Andres Floto
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, UK
- University of Cambridge Molecular Immunity Unit, MRC Laboratory of Molecular Biology, Cambridge, UK
- Cambridge Centre for AI in Medicine, University of Cambridge, Cambridge, UK
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals Trust, Cambridge, UK
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2
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Burke A, Thomson RM, Wainwright CE, Bell SC. Nontuberculous Mycobacteria in Cystic Fibrosis in the Era of Cystic Fibrosis Transmembrane Regulator Modulators. Semin Respir Crit Care Med 2023; 44:287-296. [PMID: 36649736 DOI: 10.1055/s-0042-1759883] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Nontuberculous mycobacteria (NTM) are a group of mycobacteria which represent opportunistic pathogens that are of increasing concern in people with cystic fibrosis (pwCF). The acquisition has been traditionally though to be from environmental sources, though recent work has suggested clustered clonal infections do occur and transmission potential demonstrated among pwCF attending CF specialist centers. Guidelines for the screening, diagnosis, and identification of NTM and management of pwCF have been published. The emergence of CF-specific therapies, in particular cystic fibrosis transmembrane regulator (CFTR) modulator drugs, have led to significant improvement in the health and well-being of pwCF and may lead to challenges in sampling the lower respiratory tract including to screen for NTM. This review highlights the epidemiology, modes of acquisition, screening and diagnosis, therapeutic approaches in the context of improved clinical status for pwCF, and the clinical application of CFTR modulator therapies.
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Affiliation(s)
- Andrew Burke
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Rachel M Thomson
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - Claire E Wainwright
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane, Australia
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane, Australia.,Translational Research Institute, Woolloongabba, Australia
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Bashford J, Flowers W, Haworth C, Ryan J, Cervi A, Dulayymi JRA, Mason PS, Plank A, Baird M, Floto A. Evaluation of a novel ELISA test using synthetic mycolic acid antigens for serodiagnosis of non-tuberculous mycobacterial (NTM) infections. Thorax 2023; 78:309-312. [PMID: 36627190 DOI: 10.1136/thorax-2022-218800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 11/20/2022] [Indexed: 01/12/2023]
Abstract
The diagnosis of non-tuberculous mycobacteria (NTM) is a particular challenge in people with cystic fibrosis. Current standard diagnostic approaches rely on serial sputum culture, which is resource demanding, dependent on patient expectoration and may be compromised by excessive decontamination, conventional bacterial overgrowth and masking by concomitant oral and nebulised antibiotics. An alternative rapid, reliable and inexpensive diagnostic method is therefore urgently needed. Serum of patients with Mycobacterium abscessus infection and chronic suppurative lung disease without NTM infection was tested against an array of novel synthetic mycolic acids, identical or similar to natural components of mycobacterial cell walls, and glycopeptidolipid (GPL)-core antigen, which has previously been investigated in Mycobacterium avium pulmonary infection. Diagnostic accuracy of individual antigens and combination of various antigens were calculated. An ELISA using individual trehalose dimycolates and GPL-core antigen was able to effectively distinguish serum from infected and non-infected individuals with a specificity of 88% and a sensitivity of up to 88%, which increased to 88% sensitivity and 93% specificity by combining several antigens in the test. These results suggest synthetic mycolic acid antigens, used individually or in combination with GPL-core antigen could be successfully used to distinguish patients with M. abscessus infection from disease controls.
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Affiliation(s)
- Julia Bashford
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Trust, Cambridge, UK
| | - William Flowers
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Trust, Cambridge, UK.,Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Charles Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Trust, Cambridge, UK
| | - Judy Ryan
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Trust, Cambridge, UK.,Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anna Cervi
- Diagnostig Ltd, MSParc, Gaerwen Anglesey, Wales, UK
| | - J R Al Dulayymi
- School of Natural Sciences, Bangor University, Bangor, Wales, UK
| | - Paul S Mason
- Diagnostig Ltd, MSParc, Gaerwen Anglesey, Wales, UK
| | - Ashley Plank
- Icon Cancer Foundation, Brisbane, Queensland, Australia
| | - Mark Baird
- Diagnostig Ltd, MSParc, Gaerwen Anglesey, Wales, UK
| | - Andres Floto
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Trust, Cambridge, UK .,Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
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Malcolm KC, Wheeler EA, Calhoun K, Lenhart-Pendergrass PM, Rysavy N, Poch KR, Caceres SM, Saavedra MT, Nick JA. Specificity of Immunoglobulin Response to Nontuberculous Mycobacteria Infection in People with Cystic Fibrosis. Microbiol Spectr 2022; 10:e0187422. [PMID: 35863022 PMCID: PMC9430546 DOI: 10.1128/spectrum.01874-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022] Open
Abstract
Nontuberculous mycobacteria (NTM) infections are increasingly prevalent in chronic lung diseases, including cystic fibrosis (CF). Mycobacterium abscessus is of particular concern due to relatively greater virulence and intrinsic antimicrobial resistance. Airway culture identification, the standard method for detecting pulmonary infection, is hindered by low sensitivity, long culture times, and reliance on sputum production or lavage. A culture-independent test for detecting NTM infection could complement, or replace, sputum culture, which is becoming more difficult to obtain with reduced sputum production by people with CF (pwCF) on highly effective modulator therapy. We describe an assay for the detection of plasma anti-M. abscessus antibodies of pwCF to antigens from M. abscessus lysates. Anti-M. abscessus IgG and IgA, but not IgM, discriminated with high specificity subjects infected with M. abscessus from those infected by M. avium complex, and from those with distant or no NTM infections. The IgG3 subclass predominated with minor contributions by other subclasses. Both aqueous and organic soluble antigens were recognized by plasma IgG. A validation cohort measuring IgG and IgG3 identified M. abscessus positive subjects, and elevated IgG was sustained over several years. These studies show the benefit of M. abscessus cell lysates to detect plasma IgG of subjects with CF and M. abscessus infections. Subclass analysis suggests that IgG3 is the predominant subtype in these subjects with chronic bacterial infections suggesting a defect in class maturation. Serodiagnosis could be useful to monitor M. abscessus group infections in chronic lung disease as an adjunct or alternative to culture. IMPORTANCE Lung infections with nontuberculous mycobacteria (NTM), and particularly Mycobacterium abscessus, a pathogen with high antibiotic resistance, are of great concern due to poor clinical outcomes and challenging detection in people with cystic fibrosis and other diseases. Standard detection methods are insensitive and increasingly difficult. We describe the measurement of NTM-specific antibodies from plasma to identify subjects infected with M. abscessus. The assay is sensitive and provides information on the immune response to NTM infections. This assay could be used to help identify subjects with NTM pulmonary infections and track disease progression, either alone or in conjunction with other tests.
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Affiliation(s)
- Kenneth C Malcolm
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Emily A Wheeler
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
| | - Kara Calhoun
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | | | - Noel Rysavy
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
| | - Katie R Poch
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
| | - Silvia M Caceres
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
| | - Milene T Saavedra
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Healthgrid.240341.0, Denver, Colorado, USA
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
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IgA Serological Response for the Diagnosis of Mycobacterium abscessus Infections in Patients with Cystic Fibrosis. Microbiol Spectr 2022; 10:e0019222. [PMID: 35583329 PMCID: PMC9241595 DOI: 10.1128/spectrum.00192-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The immunoglobulin A (IgA) status of cystic fibrosis (CF) patients, presenting with or without a non-tuberculous mycobacterial (NTM) infection, has to date not been fully elucidated toward two antigenic preparations previously described. We have chosen to determine the clinical values of an IgA ELISA for the diagnosis of NTM and/or Mycobacterium abscessus infections in CF patients. One hundred and 73 sera from CF patients, comprising 33 patients with M. abscessus positive cultures, and 31 non-CF healthy controls were assessed. IgA levels were evaluated by indirect ELISAs using a surface antigenic extract named TLR2eF for TLR2 positive extract and a recombinant protein, the phospholipase C (rMAB_0555 or rPLC). These assays revealed a sensitivity of 52.6% (95% CI = 35.8% to 69%) and 42.1% (95% CI = 26.3% to 59.2%) using TLR2eF and rPLC, respectively, and respective specificities of 92.6% (95% CI = 87.5% to 96.1%) and 92% (95% CI = 86.7% to 95.7%) for samples culture positive for M. abscessus. Overall sensitivity and specificity of 66.7% and 85.4%, respectively, were calculated for IgA detection in M. abscessus-culture positive CF patients, when we combine the results of the two used antigens, thus demonstrating the efficiency in detection of positive cases for these two antigens with IgA isotype. CF patients with a positive culture for M. abscessus had the highest IgA titers against TLR2eF and rPLC. The diagnosis of NTM infections, including those due to M. abscessus, can be improved by the addition of an IgA serological assay, especially when cultures, for example, are negative. Based on these promising results, a serological follow-up of a larger number of patients should be performed to determine if the IgA response may be correlated with an active/acute infection state or a very recent infection. IMPORTANCE Mycobacterium abscessus is currently the most frequently isolated rapid growing mycobacterium in human pathology and the major one involved in lung infections. It has recently emerged as responsible for severe pulmonary infections in patients with cystic fibrosis (CF) or those who have undergone lung transplantation. In addition, it represents the most antibiotic resistant mycobacterial species. However, despite its increasing clinical importance, very little is known about the use of M. abscessus parietal compounds and the host response. This has led to the development of serological tests to measure the antibody response in infected patients, and potentially to link this to the culture of respiratory samples. Herein, we describe an important analysis of the serological IgA response from CF patients, and we demonstrate the full diagnostic usefulness of this assay in the diagnosis of NTM infections, and more particularly M. abscessus, in CF patients.
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Mauch RM, Jensen PØ, Qvist T, Kolpen M, Moser C, Pressler T, Nolasco da Silva MT, Høiby N. Adaptive Immune Response to Mycobacterium abscessus Complex (MABSC) in Cystic Fibrosis and the Implications of Cross-Reactivity. Front Cell Infect Microbiol 2022; 12:858398. [PMID: 35548464 PMCID: PMC9084186 DOI: 10.3389/fcimb.2022.858398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background We aimed to characterise the adaptive immune response to Mycobacterium abscessus complex (MABSC) and its cross-reactivity with Mycobacterium avium complex (MAC) and Mycobacterium bovis (Bacille Calmette-Guérin, BCG) in cystic fibrosis (CF) patients and non-CF controls in terms of lymphocyte proliferation and immunophenotyping, cytokine production and anti-MABSC IgG plasma levels. Methods In this cross-sectional analysis, peripheral blood mononuclear cells (PBMC) from CF patients with MABSC (CF/MABSC, n=12), MAC infection history (CF/MAC, n=5), no NTM history (CF/NTM-, n=15), BCG-vaccinated (C/BCG+, n=9) and non-vaccinated controls (C/BCG-, n=8) were cultured for four days under stimulation with an in-house MABSC lysate and we used flow cytometry to assess lymphocyte proliferation (given by lymphoblast formation) and immunophenotypes. Cytokine production was assessed after overnight whole blood stimulation with the same lysate, and anti-MABSC IgG levels were measured in plasma from non-stimulated blood. Results All CF/MABSC patients had increased CD3+ and CD19+ lymphoblast formation upon PBMC stimulation with MABSC lysate. There was a higher rate of CD3+ than CD19+ lymphoblasts, predominance of CD4+ over CD8+ lymphoblasts, IFN-γ, TNF-α and IL-2 production, low production of the Th17-associated IL-17, and discrete or no production of Th2/B cell-associated cytokines soluble CD40 ligand (CD40L), IL-4 and IL-5, indicating a Th1-dominated phenotype and infection restricted to the lungs. A similar pattern was seen in C/BCG+ controls, and CF/MAC patients, pointing to cross-reactivity. MABSC-IgG levels were higher in CF/MABSC patients than in both control groups, but not CF/NTM- patients, most of whom also had CD3+ and/or CD19+ lymphoblast formation upon PBMC stimulation, indicating previous exposure, subclinical or latent infection with MABSC or other NTM. Conclusion The anti-MABSC immune response is Th1-skewed and underlines the cross-reactivity in the anti-mycobacterial immune response. The results, together with published clinical observations, indicate that BCG vaccination may cross-react against NTM in CF patients, and this should be investigated. Due to cross-reactivity, it would also be interesting to investigate whether a combination of MABSC-induced cytokine production by blood cells and anti-MABSC IgG measurement can be useful for identifying latent or subclinical infection both with MABSC and other NTM in CF patients.
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Affiliation(s)
- Renan Marrichi Mauch
- Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark.,Institute of Inflammation Research, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | - Tavs Qvist
- Cystic Fibrosis Adult Clinic , Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | - Mette Kolpen
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Tacjana Pressler
- Cystic Fibrosis Adult Clinic , Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | | | - Niels Høiby
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
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