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Hasmukharay K, Ngoi ST, Saedon NI, Tan KM, Khor HM, Chin AV, Tan MP, Kamarulzaman A, Idris NB, Niek WK, Teh CSJ, Kamaruzzaman SBB, Ponnampalavanar SSLS. Evaluation of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia: Epidemiology, clinical characteristics, and outcomes in the older patients in a tertiary teaching hospital in Malaysia. BMC Infect Dis 2023; 23:241. [PMID: 37072768 PMCID: PMC10111773 DOI: 10.1186/s12879-023-08206-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/30/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a major concern in the global healthcare system. However, data from Asian regions dealing with the singularity of this infection in older persons is lacking. We aimed to identify the differences in the clinical characteristics and outcomes of MRSA bacteremia between adults aged 18-64 and ≥ 65 years. METHODS A retrospective study cohort was conducted at the University Malaya Medical Centre (UMMC) on cases of MRSA bacteremia from 2012 to 2016. Patient demographic and clinical data were collected for risk factors analyses. RESULTS New cases of MRSA bacteremia showed a trend of increase from 0.12 to 100 admissions in 2012 to 0.17 per 100 admissions in 2016 but a drop was observed in 2014 (0.07 per 100 admissions). Out of the 275 patients with MRSA bacteremia, 139 (50.5%) patients were aged ≥ 65 years old. Co-morbidities and severity at presentation were significantly higher among older adults, including diabetes mellitus (p = 0.035), hypertension (p = 0.001), and ischemic heart disease (p < 0.001), as well as higher Charlson Comorbidity Index (p < 0.001) and Pitt bacteremia scores (p = 0.016). Central line-associated bloodstream infections were more common among younger patients (37.5% vs. 17.3% in older patients, p < 0.001), while skin and soft tissue infections are more frequent among older adults (20.9% vs. 10.3% in younger patients, p = 0.016). All-cause mortality and in-hospital mortality were significantly higher in older patients (82.7% and 56.1% vs. 63.2% and 28.7% in younger patients, p < 0.001). Multivariate analysis revealed age ≥ 65 years (adjusted odds ratio: 3.36; 95% confidence interval: 1.24-9.13), Pitt score ≥ 3 (2.15; 1.54-3.01), hospital (6.12; 1.81-20.72) and healthcare (3.19; 1.30-7.81) acquisition of MRSA, indwelling urinary catheters (5.43; 1.39-21.23), inappropriate targeted treatment (8.08; 1.15-56.86), lack of infectious disease team consultation (2.90; 1.04-8.11) and hypoalbuminemia (3.31; 1.25-8.79), were significant risk factors for 30-day mortality. CONCLUSION Older patients' risk of mortality from MRSA bacteremia was three times higher than younger patients. Our data will contribute to developing and validating a robust scoring system for risk-stratifying patients to achieve better management and improved clinical outcomes.
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Affiliation(s)
- Kejal Hasmukharay
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Soo Tein Ngoi
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Nor Izzati Saedon
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kit Mun Tan
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Hui Min Khor
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Ai Vyrn Chin
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Maw Pin Tan
- Geriatric Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Adeeba Kamarulzaman
- Infectious Disease Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Nuryana Binti Idris
- Department of Medical Microbiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Wen Kiong Niek
- Department of Medical Microbiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Cindy Shuan Ju Teh
- Department of Medical Microbiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
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Abstract
PURPOSE OF REVIEW To highlight the peculiarity of skin and soft tissue infections (SSTIs) in elderly patients and to provide useful elements for their optimal management. RECENT FINDINGS In the COVID-19 era, early discharge from the hospital and implementation of outpatient management is of key importance. SUMMARY Elderly patients are at high risk of SSTIs due to several factors, including presence of multiple comorbidities and skin factors predisposing to infections. Clinical presentation may be atypical and some signs of severity, such as fever and increase in C-reactive protein, may be absent or aspecific in this patients population. An appropriate diagnosis of SSTIs in the elderly is crucial to avoid antibiotic overtreatment. Further studies should explore factors associated with bacterial superinfections in patients with pressure ulcers or lower limb erythema. Since several risk factors for methicillin-resistant Staphylococcus aureus (MRSA) may coexist in elderly patients, these subjects should be carefully screened for MRSA risk factors and those with high risk of resistant etiology should receive early antibiotic therapy active against MRSA. Physicians should aim to several objectives, including clinical cure, patient safety, early discharge and return to community. SSTIs in the elderly may be managed using long-acting antibiotics, but clinical follow-up is needed.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
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Relationship between mortality and molecular epidemiology of methicillin-resistant Staphylococcus aureus bacteremia. PLoS One 2022; 17:e0271115. [PMID: 35802589 PMCID: PMC9269358 DOI: 10.1371/journal.pone.0271115] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/23/2022] [Indexed: 11/22/2022] Open
Abstract
Staphylococcus aureus is the primary cause of bacteremia, and methicillin-resistant S. aureus bacteremia is associated with a high mortality rate. Methicillin-resistant S. aureus clones are widespread worldwide, and molecular epidemiological studies are important. Therefore, this study aimed to determine the characteristics of patients who died due to methicillin-resistant S. aureus bacteremia and microbiological characteristics of methicillin-resistant S. aureus strains in a tertiary teaching hospital. This single-center, retrospective study included patients with methicillin-resistant S. aureus isolated from blood bacterial culture performed at Kyoto Prefectural University of Medicine Hospital, from October 2016 to May 2019. The data analyzed included patient background, clinical strain characteristics, and molecular epidemiology. Of 41 patients with methicillin-resistant S. aureus bacteremia (median age, 60 [28–70] years; 24 (59%) were men), and 7 (17%) died due to methicillin-resistant S. aureus bacteremia. The median age of those who died in the methicillin-resistant S. aureus bacteremia group was predominantly higher than that of those in the alive group (p = 0.03). The most common cause of methicillin-resistant S. aureus bacteremia was endovascular devices, which occurred in 20 (49%), 18 (53%), and 2 (29%) patients in the total, alive, and died groups, respectively. Bacteriological characteristics showed that type IV Staphylococcal Cassette Chromosome mec genotype was most frequently detected in the total (n = 34 [83%]), alive (n = 29 [85%]), and died (n = 5 [71%]) groups. In the molecular cluster analysis, CC8, ST8, staphylococcal Cassette Chromosome mec type IV, and community-acquired-methicillin-resistant S. aureus formed the largest groups. The diversity of methicillin-resistant S. aureus clones is evident, and it is possible that clones with new virulence factors may still emerge. In the future, it will be crucial to monitor the epidemiological trends of methicillin-resistant S. aureus to respond quickly to changes in pathogenic and clonal factors, to clarify the gene expression network by identifying old and new virulence factors.
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Bloodstream infections in the elderly: what is the real goal? Aging Clin Exp Res 2021; 33:1101-1112. [PMID: 31486996 DOI: 10.1007/s40520-019-01337-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Abstract
Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.
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Giovannenze F, Murri R, Palazzolo C, Taccari F, Camici M, Spanu T, Posteraro B, Sanguinetti M, Cauda R, Onder G, Fantoni M. Predictors of mortality among adult, old and the oldest old patients with bloodstream infections: An age comparison. Eur J Intern Med 2021; 86:66-72. [PMID: 33414015 DOI: 10.1016/j.ejim.2020.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/30/2020] [Accepted: 12/24/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bloodstream infections (BSIs) are a major cause of mortality in elderly. Objective of the study is to identify factors predictive of mortality in old and oldest old patients. METHODS This is a single centre retrospective observational study, including all patients admitted to Fondazione Policlinico A. Gemelli university hospital and diagnosed with BSI. Patients were stratified into three groups according to age: adult (A), younger than 65; old (O), aged between 65 and 80; oldest old (OO), older than 80. Primary outcome was 30-day in-hospital mortality. Secondary outcomes were duration of antimicrobial therapy (DOT) and length of hospital stay (LOS). RESULTS Of the 1034 patients included in the study, 346 were in group A, 447 in group O and 241 in group OO. The rate of 30-day mortality raised from 6.9% (24/346) in group A to 10.8% (84/447) in group O and 33.2% (80/241) in group OO (p<0.01), while DOT and LOS significantly decreased moving from adults to oldest old (p<0.01). Methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus spp were both independently correlated to an increased 30-day mortality risk selectively in patients older than 80 (MRSA: HR 2.37, p=0.03; Enterococcus spp: HR 2.44, p=0.01). CONCLUSIONS BSIs have a high impact on survival in old and oldest old patients. BSIs by gram-positive pathogens, in particular MRSA and Enterococcus spp, should be a wake-up call for physicians, who should focus efforts on adequate and prompt antibiotic and support treatment.
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Affiliation(s)
- Francesca Giovannenze
- Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy.
| | - Rita Murri
- Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Claudia Palazzolo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Francesco Taccari
- Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Marta Camici
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Teresa Spanu
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy; Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy
| | - Roberto Cauda
- Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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Bassetti M, Righi E, Del Giacomo P, Sartor A, Ansaldi F, Trucchi C, Alicino C, Trecarichi EM, Spanu T, Paganino C, Tumbarello M, Carnelutti A. Predictors of Mortality with Staphylococcus aureus Bacteremia in Elderly Adults. J Am Geriatr Soc 2018; 66:1284-1289. [PMID: 29664994 DOI: 10.1111/jgs.15391] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To analyze risk factors for early and late mortality in individuals aged 75 and older with Staphylococcus aureus bacteremia (SAB) in Italy. DESIGN Four-year retrospective observational study (January 2011-December 2014). SETTING Two tertiary care university hospitals in Italy (Santa Maria Misericordia Hospital in Udine, Policlinico Universitario Agostino Gemelli in Rome). PARTICIPANTS All adults consecutively admitted with SAB. MEASUREMENTS Clinical presentation, infection characteristics, and clinical outcomes of individuals aged 75 and older were compared with those of individuals younger than 75. RESULTS Three hundred thirty-seven cases of SAB were diagnosed during the study period, 118 of which (35%) occurred in those aged 75 and older. Seven- (20.3% vs 9.2%) and 30-day (35.7% vs 20.7%) mortality were significantly higher in elderly than younger adults. Clinical presentation with septic shock, adequacy of empiric antibiotic treatment, and liver cirrhosis were found to be predictors of 7-day mortality in elderly adults with SAB. Risk factors independently associated with 30-day mortality included isolation of methicillin-resistant Staphylococcus aureus (MRSA) and not receiving an infectious disease consultation. CONCLUSION Mortality is significantly higher in elderly than in younger adults with SAB, particularly in those presenting with septic shock, liver cirrhosis, or SAB due to MRSA. Additional risk factors for mortality included inappropriate empiric antibiotic treatment and not receiving an infectious disease consultation.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia Hospital and University of Udine, Udine, Italy
| | - Elda Righi
- Santa Maria Misericordia Hospital and University of Udine, Udine, Italy
| | - Paola Del Giacomo
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Assunta Sartor
- Santa Maria Misericordia Hospital and University of Udine, Udine, Italy
| | - Filippo Ansaldi
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Cecilia Trucchi
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Enrico Maria Trecarichi
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Teresa Spanu
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Chiara Paganino
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Mario Tumbarello
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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de la Fuente Aguado J, Lamas Ferreiro J. La edad como factor diferencial en el paciente con bacteriemia. Rev Clin Esp 2017; 217:28-29. [DOI: 10.1016/j.rce.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 11/26/2022]
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Hos NJ, Jazmati N, Stefanik D, Hellmich M, AlSael H, Kern WV, Rieg S, Wisplinghoff H, Seifert H, Kaasch AJ. Determining vancomycin Etest MICs in patients with MRSA bloodstream infection does not support switching antimicrobials. J Infect 2016; 74:248-259. [PMID: 28017826 DOI: 10.1016/j.jinf.2016.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/16/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Elevated vancomycin minimum inhibitory concentrations (MIC) have been reported to adversely affect clinical outcome in methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI). We therefore examined the association between vancomycin MIC and outcome considering various potential confounders. METHODS Clinical data and bacterial isolates were prospectively collected from patients with MRSA BSI from 2006 to 2012 as part of the Invasive Staphylococcus aureus Infection Cohort (INSTINCT) study. Antimicrobial susceptibility was assessed by Etest, broth microdilution (BMD) and VITEK 2. Bacterial genotypes were determined by spa typing. Using univariate and Cox regression analyses, we investigated the impact of low (≤1.0 mg/L) and high (≥1.5 mg/L) vancomycin Etest MIC on clinical outcomes. RESULTS Ninety-one MRSA BSI episodes were included, of which 79 (86.8%) were caused by spa types t003, t032 and t045. High vancomycin MICs were seen only if using Etest but not confirmed using standard reference BMD. When episodes were stratified into low and high vancomycin Etest MIC groups, 30-day overall mortality was 34.5% and 27.3%, respectively (P = 0.64, OR 0.71; 95% confidence interval [CI] 0.27-1.79). Variables significantly associated with all-cause mortality in the Cox model were age (P = 0.003), acute physiology score (P = 0.0006), and Charlson comorbidity index (P = 0.018). CONCLUSIONS Vancomycin MICs may vary dependent on testing methodologies and local MRSA epidemiology. The patients' underlying disease and individual comorbidities rather than elevated vancomycin MICs determine adverse clinical outcomes in MRSA BSI. Routine Etest MIC testing of MRSA isolates is of limited value for treatment decisions.
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Affiliation(s)
- Nina J Hos
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Diseases, University of Cologne, Joseph-Stelzmann-Str. 26, 50931 Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Germany
| | - Nathalie Jazmati
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Danuta Stefanik
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Halil AlSael
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Hilmar Wisplinghoff
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Germany.
| | - Achim J Kaasch
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine University Düsseldorf, Universitätsstr. 1, 40225 Düsseldorf, Germany
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