1
|
Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
Collapse
Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| |
Collapse
|
2
|
Duplessis C, Clarkson KA, Ross Turbyfill K, Alcala AN, Gutierrez R, Riddle MS, Lee T, Paolino K, Weerts HP, Lynen A, Oaks EV, Porter CK, Kaminski R. GMP manufacture of Shigella flexneri 2a Artificial Invaplex (Invaplex AR) and evaluation in a Phase 1 Open-label, dose escalating study administered intranasally to healthy, adult volunteers. Vaccine 2023; 41:6261-6271. [PMID: 37666695 DOI: 10.1016/j.vaccine.2023.08.051] [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: 05/12/2023] [Revised: 07/14/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
Shigella species cause severe disease among travelers to, and children living in, endemic countries. Although significant efforts have been made to improve sanitation, increased antibiotic resistance and other factors suggest an effective vaccine is a critical need. Artificial Invaplex (InvaplexAR) is a subunit vaccine approach complexing Shigella LPS with invasion plasmid antigens. In pre-clinical studies, the InvaplexAR vaccine demonstrated increased immunogenicity as compared to the first generation product and was subsequently manufactured under cGMP for clinical testing in a first-in-human Phase 1 study. The primary objective of this study was the safety of S. flexneri 2a InvaplexAR given by intranasal (IN) immunization (without adjuvant) in a single-center, open-label, dose-escalating Phase 1 trial and secondarily to assess immunogenicity to identify a dose of InvaplexAR for subsequent clinical evaluations. Subjects received three IN immunizations of InvaplexAR, two weeks apart, in increasing dose cohorts (10 µg, 50 µg, 250 µg, and 500 μg). Adverse events were monitored using symptom surveillance, memory aids, and targeted physical exams. Samples were collected throughout the study to investigate vaccine-induced systemic and mucosal immune responses. There were no adverse events that met vaccination-stopping criteria. The majority (96%) of vaccine-related adverse events were mild in severity (most commonly nasal congestion, rhinorrhea, and post-nasal drip). Vaccination with InvaplexAR induced anti-LPS serum IgG responses and anti-Invaplex IgA and IgG antibody secreting cell (ASC) responses at vaccine doses ≥250 µg. Additionally, mucosal immune responses and functional antibody responses were seen from the serum bactericidal assay measurements. Notably, the responder rates and the kinetics of ASCs and antibody lymphocyte secretion (ALS) were similar, suggesting that either assay may be employed to identify IgG and IgA secreting cells. Further studies with InvaplexAR will evaluate alternative immunization routes, vaccination schedules and formulations to further optimize immunogenicity. (Clinical Trial Registry Number NCT02445963).
Collapse
Affiliation(s)
- Christopher Duplessis
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: University of Nevada Reno, Reno, NV, USA
| | - Kristen A Clarkson
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Horizon Therapeutics, Deerfield, IL, USA
| | - K Ross Turbyfill
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
| | - Ashley N Alcala
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: Tigermed-BDM, Somerset, NJ, USA
| | - Ramiro Gutierrez
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: Upstate Medical University, Syracuse, NY, USA
| | - Mark S Riddle
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: University of Nevada Reno, Reno, NV, USA
| | - Tida Lee
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Kristopher Paolino
- Clinical Trials Center, Division of Translational Medicine, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Upstate Medical University, Syracuse, NY, USA
| | - Hailey P Weerts
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: National Institute of Allery and Infectious Diseases, Bethesda, MD, USA
| | - Amanda Lynen
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Edwin V Oaks
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Patuxent Research and Consulting Group, Gambrills, MD, USA
| | - Chad K Porter
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Robert Kaminski
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Latham BioPharm Group, Cambridge, MA, USA
| |
Collapse
|
3
|
Quino W, Bellido G, Flores-León D, Caro-Castro J, Mestanza O, Lucero J, Gavilan RG. Trends in antimicrobial resistance of Shigella species in Peru, 2011-2020. JAC Antimicrob Resist 2023; 5:dlad110. [PMID: 37901588 PMCID: PMC10600570 DOI: 10.1093/jacamr/dlad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/20/2023] [Indexed: 10/31/2023] Open
Abstract
Objective To describe the frequency of antimicrobial resistance rates and spatial-temporal distribution of Shigella species from the last 10 years in Peru. Methods A cross-sectional descriptive study was carried out. A total of 1668 Shigella strains, remitted as part of the national enteric pathogen surveillance from 2011 to 2020, were analysed. The strains were confirmed by conventional tests and serotyped with polyvalent and monovalent antibodies. Also, antimicrobial susceptibility was performed according to the Kirby-Bauer method. Results The most frequent Shigella species was S. sonnei (49.2%), followed by S. flexneri (42.2%), S. boydii (7.9%) and S. dysenteriae (0.7%). Phase II (46.29%) was the most frequent serotype in S. sonnei, serotype 2a (43.61%) in S. flexneri, serotype 2 in S. boydii and serotype 4 in S. dysenteriae. High rates of resistance were detected for trimethoprim/sulfamethoxazole (91.0%), tetracycline (88.4%), ampicillin (73.9%) and chloramphenicol (64.9%), moderate rates for amoxicillin/clavulanic acid (25.1%), ciprofloxacin (16.7%) and nalidixic acid (14.8%), and low rates for cefotaxime (1.74%), nitrofurantoin (0.7%) and ceftazidime (0.6%). Moreover, antimicrobial resistance to fluoroquinolones increased considerably from 2017 to 2020. Conclusion S. sonnei was the most frequent species, which have a large proportion of strains resistant to trimethoprim/sulfamethoxazole, and a growing trend of resistance to ciprofloxacin and nalidixic acid. This increase in resistance to commonly used antibiotics in treatments is alarming, threatening the control and management of these currently treatable infections.
Collapse
Affiliation(s)
- Willi Quino
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
| | - Gustavo Bellido
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
| | - Diana Flores-León
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
- Escuela Profesional de Medicina Humana, Universidad Privada San Juan Bautista, Lima, Perú
| | - Junior Caro-Castro
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
| | - Orson Mestanza
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
| | - Jorge Lucero
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
| | - Ronnie G Gavilan
- Laboratorio de Referencia Nacional de Bacteriología Clínica, Instituto Nacional de Salud, Lima, Perú
- Escuela Profesional de Medicina Humana, Universidad Privada San Juan Bautista, Lima, Perú
| |
Collapse
|
4
|
Baharvand A, Molaeipour L, Alesaeidi S, Shaddel R, Mashatan N, Amiriani T, Kiaei Sudkolaei M, Abbasian S, Talib Al-Naqeeb BZ, Kouhsari E. The increasing antimicrobial resistance of Shigella species among Iranian pediatrics: a systematic review and meta-analysis. Pathog Glob Health 2023; 117:611-622. [PMID: 36794800 PMCID: PMC10498791 DOI: 10.1080/20477724.2023.2179451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Shigellosis remains one of the global causes of morbidity and mortality. However, the global emergence of antibiotic resistance has become the leading cause of treatment failure in shigellosis. This review aimed to provide an updated picture of the antimicrobial resistance rates in Shigella species in Iranian pediatrics. METHODS A comprehensive systematic search was performed on PubMed, Scopus, Embase, and Web of Science until 28 July 2021. The meta-analysis was performed by computing the pooled using a random-effects model with Stata/SE software, v.17.1. The discrepancy within articles was surveyed by the forest plot in addition to the I2 statistic. All statistical interpretations were reported on a 95% confidence interval (CI) basis. RESULTS Totally, of 28 eligible studies published between 2008 and 2021. The pooled prevalence rate of multidrug-resistant (MDR) was 63% (95% CI 50-76). Regarding suggested antimicrobial agents for Shigella species, the prevalence of resistance for ciprofloxacin, azithromycin, and ceftriaxone as first- and second-line treatments for shigellosis were 3%, 30%, and 28%, respectively. In contrast, resistance to cefotaxime, cefixime, and ceftazidime was 39%, 35%, and 20%. Importantly, subgroup analyses indicated that an increase in resistance rates during the periods (2008-2014, 2015-2021) was recognized for ciprofloxacin (0 % to 6%) and ceftriaxone (6% to 42%). CONCLUSION Our findings revealed that ciprofloxacin is an effective drug for shigellosis in Iranian children. The substantially high prevalence estimation proposes that the first- and second-line treatments for shigellosis are the major threat to public health and active antibiotic treatment policies are essential.
Collapse
Affiliation(s)
| | - Leila Molaeipour
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Sogol Alesaeidi
- Department of Pediatric Medicine, Imam Hossein Hospital, Resident of pediatric medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reyhane Shaddel
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Noushin Mashatan
- Graduated, School of Applied Sciences, University of Brighton, Brighton, UK
| | - Taghi Amiriani
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Melika Kiaei Sudkolaei
- Department of Nutrition, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | - Sara Abbasian
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | | | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
- Department of Laboratory Sciences, Faculty of Paramedicine, Golestan University of Medical Sciences, Gorgan, Iran
| |
Collapse
|
5
|
Wang Y, Teng Y, Geng J, Long J, Yang H, Duan G, Chen S. Involvement of RNA chaperone Hfq in the regulation of antibiotic resistance and virulence in Shigella sonnei. Res Microbiol 2023:104047. [PMID: 36868486 DOI: 10.1016/j.resmic.2023.104047] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
The host factor for RNA phage Qβ replicase (Hfq) is a crucial post-transcriptional regulator in many bacterial pathogens, facilitating the interaction between small non-coding RNAs (sRNAs) and their target mRNAs. Studies have suggested that Hfq plays a role in antibiotic resistance and virulence in bacteria, although its functions in Shigella are not fully understood. In this study, we investigated the functional roles of Hfq in Shigella sonnei (S. sonnei) by constructing an hfq deletion mutant. Our phenotypic assays showed that the hfq deletion mutant was more sensitivity to antibiotics and had impaired virulence. Transcriptome analyses supported the results concerning the phenotype of the hfq mutant and showed that differentially expressed genes were mainly enriched in the KEGG pathways two-component system, ABC transporters, ribosome, and Escherichia coli biofilm formation. Additionally, we predicted eleven novel Hfq-dependent sRNAs, which were potentially involved in the regulation of antibiotic resistance and/or virulence in S. sonnei. Our findings suggest that Hfq plays a post-transcriptional role in regulating antibiotic resistance and virulence in S. sonnei, and could provide a basis for future studies on Hfq-sRNA-mRNA regulatory networks in this important pathogen.
Collapse
Affiliation(s)
- Ya Wang
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Yanli Teng
- Henan Province Center for Disease Control and Prevention, Zhengzhou, China
| | - Juan Geng
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Jinzhao Long
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Haiyan Yang
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Guangcai Duan
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Shuaiyin Chen
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou, China.
| |
Collapse
|
6
|
Determining β-lactam antibiotics in aquaculture products by modified QuECHERS combined with ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). ARAB J CHEM 2022. [DOI: 10.1016/j.arabjc.2022.103912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
7
|
Shigella sonnei: virulence and antibiotic resistance. Arch Microbiol 2020; 203:45-58. [PMID: 32929595 PMCID: PMC7489455 DOI: 10.1007/s00203-020-02034-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 12/21/2022]
Abstract
Shigella sonnei is the emerging pathogen globally, as it is the second common infectious species of shigellosis (bloody diarrhoea) in low- and middle-income countries (LMICs) and the leading one in developed world. The multifactorial processes and novel mechanisms have been identified in S. sonnei, that are collectively playing apart a substantial role in increasing its prevalence, while replacing the S. flexneri and other Gram-negative gut pathogens niche occupancy. Recently, studies suggest that due to improvement in sanitation S. sonnei has reduced cross-immunization from Plesiomonas shigelliodes (having same O-antigen as S. sonnei) and also found to outcompete the two major species of Enterobacteriaceae family (Shigella flexneri and Escherichia coli), due to encoding of type VI secretion system (T6SS). This review aimed to highlight S. sonnei as an emerging pathogen in the light of recent research with pondering aspects on its epidemiology, transmission, and pathogenic mechanisms. Additionally, this paper aimed to review S. sonnei disease pattern and related complications, symptoms, and laboratory diagnostic techniques. Furthermore, the available treatment reigns and antibiotic-resistance patterns of S. sonnei are also discussed, as the ciprofloxacin and fluoroquinolone-resistant S. sonnei has already intensified the global spread and burden of antimicrobial resistance. In last, prevention and controlling strategies are briefed to limit and tackle S. sonnei and possible future areas are also explored that needed more research to unravel the hidden mysteries surrounding S. sonnei.
Collapse
|
8
|
Farajzadeh Sheikh A, Moradi Bandbal M, Saki M. Emergence of multidrug-resistant Shigella species harboring extended-spectrum beta-lactamase genes in pediatric patients with diarrhea from southwest of Iran. Mol Biol Rep 2020; 47:7097-7106. [PMID: 32894435 DOI: 10.1007/s11033-020-05776-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/28/2020] [Indexed: 11/29/2022]
Abstract
Owing to the scarce evidence about the multidrug-resistant (MDR) beta-lactamase-producing Shigella isolates in Iran, this study aimed to evaluate the occurrence of extended-spectrum beta-lactamases (ESBL) and AmpC β-lactamases in Shigella species collected in the southwest of Iran. This study was conducted on Shigella species isolated from stool samples of pediatric patients aged less than 15 years suffering from diarrhea. These isolates were identified by bacteriology tests, serotyping, and polymerase chain reaction (PCR). The antibiotic resistance was determined by disc diffusion. The production of ESBLs and AmpC was investigated by phenotypic confirmatory tests and PCR. In total, 79 Shigella isolates, including 46.8% (n = 37) of S. flexneri and 53.2% (n = 42) of S. sonnei, were isolated, respectively. The most effective antibiotic was imipenem with 93.7% of susceptibility followed by ampicillin (29.1%), and cotrimoxazole (30.4%).The resistance rates of ceftriaxone, ceftazidime, and cefotaxime were 41.8%, 34.2%, and 41.8%, respectively. Also, a total of 57 (72.2%) isolates showed MDR profiles. The phenotypic tests showed that 43.0% (34/79) of isolates can produce ESBLs, and no one was positive for ApmC. The frequency of blaTEM and blaCTX-M were 30.4% and 32.9%, respectively, while the blaPER, blaSHV, and AmpC genes were not detected. The ESBL-producing isolates had a significant (p-value ˂ 0.05) resistance rate against ceftriaxone, ceftazidime, cefotaxime, cefepime, erythromycin, and amikacin. The significant prevalence of MDR Shigella isolates harboring ESBL genes highlights the need for effective surveillance measures to prevent the more spread of drug resistance among species.
Collapse
Affiliation(s)
- Ahmad Farajzadeh Sheikh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Moradi Bandbal
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. .,Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Morteza Saki
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| |
Collapse
|
9
|
da Cruz Gouveia MA, Lins MTC, da Silva GAP. Acute diarrhea with blood: diagnosis and drug treatment. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
10
|
da Cruz Gouveia MA, Lins MTC, da Silva GAP. Acute diarrhea with blood: diagnosis and drug treatment. J Pediatr (Rio J) 2020; 96 Suppl 1:20-28. [PMID: 31604059 PMCID: PMC9432323 DOI: 10.1016/j.jped.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVE To restate the epidemiological importance of Shigella in acute diarrhea with blood, providing an overview of the treatment and stressing the need for the correct indication of antibiotic therapy. SOURCES OF DATA A search was carried out in the Medline and Scopus databases, in addition to the World Health Organization scientific documents and guidelines, identifying review articles and original articles considered relevant to substantiate the narrative review. SYNTHESIS OF DATA Different pathogens have been associated with acute diarrhea with blood; Shigella was the most frequently identified. The manifestations of shigellosis in healthy individuals are usually of moderate intensity and disappear within a few days. There may be progression to overt dysentery with blood and mucus, lower abdominal pain, and tenesmus. Conventional bacterial stool culture is the gold standard for the etiological diagnosis; however, new molecular tests have been developed to allow the physician to initiate targeted antibacterial treatment, addressing a major current concern caused by the increasing resistance of Shigella. Prevention strategies include breastfeeding, hygiene measures, health education, water treatment, and the potential use of vaccines. CONCLUSIONS Acute diarrhea is an important cause of mortality in children under 5 years and shigellosis is the leading cause of acute diarrhea with blood worldwide. The current concern is the increase in microbial resistance to the recommended antibiotics, which brings an additional difficulty to therapeutic management. Although no vaccine is yet available against Shigella, several candidates are undergoing clinical trials, and this may be the most cost-effective preventative measure in future.
Collapse
Affiliation(s)
- Mara Alves da Cruz Gouveia
- Universidade Federal de Pernambuco (UFPE), Saúde da Criança e do Adolescente, Recife, PE, Brazil; Universidade Federal de Pernambuco (UFPE), Centro de Ciências Médicas, Pediatria, Recife, PE, Brazil
| | - Manuela Torres Camara Lins
- Universidade Federal de Pernambuco (UFPE), Saúde da Criança e do Adolescente, Recife, PE, Brazil; Universidade Federal de Pernambuco (UFPE), Centro de Ciências Médicas, Pediatria, Recife, PE, Brazil
| | | |
Collapse
|
11
|
Jain PA, Kulkarni RD, Dutta S, Ganavali AS, Kalabhavi AS, Shetty PC, Shubhada C, Hosamani MA, Appannanavar SB, Hanamaraddi DR. Prevalence and antimicrobial profile of Shigella isolates in a tertiary care hospital of North Karnataka: A 12-year study. Indian J Med Microbiol 2020; 38:101-108. [PMID: 32719216 DOI: 10.4103/ijmm.ijmm_20_107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Context Shigella is a common cause of bacillary dysentery. Although it is reported worldwide, the majority of the infections are seen in developing countries with Shigella flexneri being the most common isolate. Prevalence of Shigella species and their antibiotic susceptibility profiles vary according to geographic area and season. Aims In the present study, the epidemiology and antimicrobial profile of Shigella from stool samples received at our hospital for a period of 12 years (January 2006 to December 2017) was evaluated. Subjects and Methods A total of 4578 stool samples were collected from the cases of acute gastroenteritis and diarrhoea. Samples were processed for culture and sensitivity according to standard microbiological techniques. The presumptive identification of Shigella species was done using standard conventional biochemical tests and confirmed using antisera. Results A total of 189 (4.2%) samples yielded Shigella spp. Isolation of Shigella spp. were more frequent from males (58.2%). S. flexneri was the commonest species isolated (47.6%) followed by Shigella sonnei(11.6%), Shigella dysenteriae (4.2%) and Shigella boydii (2.1%). Non-typeable Shigella was commonly recovered. The isolates showed high resistance to ampicillin (76.7%) and co-trimoxazole (75%) while highest susceptibility was observed to ceftriaxone (79.2%). Conclusions S. flexneri was the most prevalent species isolated at this centre. Shigella isolates from the study showed alarming resistance to recommended antibiotics. Non-typeable Shigella accounted for 34.4% isolates. Molecular discrimination between Shigella and Escherichia coli is essential.
Collapse
Affiliation(s)
| | - R D Kulkarni
- Department of Microbiology, SDMCMSH, Dharwad, Karnataka, India
| | - S Dutta
- ICMR-National Institute of Cholera and Enteric Diseases and Officer-in-Charge, ICMR-Virus Unit, Kolkata, West Bengal, India
| | | | | | | | - C Shubhada
- Department of Microbiology, SDMCMSH, Dharwad, Karnataka, India
| | | | | | | |
Collapse
|
12
|
Shakoor S, Platts-Mills JA, Hasan R. Antibiotic-Resistant Enteric Infections. Infect Dis Clin North Am 2019; 33:1105-1123. [DOI: 10.1016/j.idc.2019.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
13
|
Duan XY, Zhang Y, Yan JQ, Zhou Y, Li GH, Feng XS. Progress in Pretreatment and Analysis of Cephalosporins: An Update Since 2005. Crit Rev Anal Chem 2019; 51:55-86. [PMID: 31646873 DOI: 10.1080/10408347.2019.1676194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Xiao-Yi Duan
- School of Pharmacy, China Medical University, Shenyang, China
| | - Yuan Zhang
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia-Qing Yan
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhou
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guo-Hui Li
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Song Feng
- School of Pharmacy, China Medical University, Shenyang, China
| |
Collapse
|
14
|
Khademi F, Sahebkar A. Fluoroquinolones-resistant Shigella species in Iranian children: a meta-analysis. World J Pediatr 2019; 15:441-453. [PMID: 31154582 DOI: 10.1007/s12519-019-00263-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/29/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Shigella is one of the most common causes of childhood dysentery along with high rate of morbidity and mortality in both developing and developed countries. According to the World Health Organization (WHO) reports, the prevalence of fluoroquinolones-resistant Shigella species is increasing worldwide which can cause treatment failure of Shigella infections. Since there has not been any comprehensive information on drug-resistant Shigella species in Iran, we conducted the following meta-analysis to raise awareness. METHODS We conducted a literature search on antibiotic resistance of Shigella species to collect published studies in Iran using national and international databases. Literature search was performed by up to Jan 30, 2019 and eligible studies were included in the meta-analysis by predefined criteria. RESULTS Antimicrobial susceptibility testing using disk diffusion technique was the only used method in all included studies. Antibiotic resistance characteristics of Shigella species against WHO recommended therapeutic regimens were as follows: S. dysenteriae 7%, S. flexneri 3.8%, S. boydii 6.9% and S. sonnei 2.6% to ciprofloxacin, S. dysenteriae 27.9%, S. flexneri 19.3%, S. boydii 15.7% and S. sonnei 9.5% to ceftriaxone and also S. dysenteriae 91.7%, S. flexneri 20.7%, S. boydii 46.7% and S. sonnei 32.3% to azithromycin. Resistance to pivmecillinam has not been investigated in Iran. CONCLUSIONS Our findings revealed that ciprofloxacin can still be used as the first-line antibiotic for Shigella infections in Iranian children. However, it seems that second-line antibiotics i.e., ceftriaxone and azithromycin are not good choices for treatment and thus not recommended.
Collapse
Affiliation(s)
- Farzad Khademi
- Department of Microbiology, School of Medicine, Ardabil University of Medical Sciences, Daneshgah Street, Ardabil, 5618985991, Iran.
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
15
|
Sati HF, Bruinsma N, Galas M, Hsieh J, Sanhueza A, Ramon Pardo P, Espinal MA. Characterizing Shigella species distribution and antimicrobial susceptibility to ciprofloxacin and nalidixic acid in Latin America between 2000-2015. PLoS One 2019; 14:e0220445. [PMID: 31374081 PMCID: PMC6677304 DOI: 10.1371/journal.pone.0220445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/16/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Shigellosis is the second leading cause of diarrheal death globally. The global burden has been complicated by the emergence of Shigella strains resistant to first line antibiotic treatments such as ciprofloxacin. This study aims to describe the epidemiologic distribution of the most common Shigella species, and their antimicrobial susceptibility patterns to ciprofloxacin and nalidixic acid (NA) in Latin America. METHODS Laboratory data from 19 countries were obtained through the Latin American Network for Antimicrobial Resistance Surveillance (ReLAVRA) from 2000-2015. The Clinical Laboratory Standards Institute reduced susceptibility breakpoints for Enterobacteriaceae was used to interpret the disc diffusion tests for Shigella susceptibility to ciprofloxacin and NA. Negative binominal regression was used to analyze longitudinal trends of Shigella isolates antimicrobial susceptibility. RESULTS 79,548 Shigella isolates were tested and reported between 2000-2015. The most common isolated species were S. flexneri (49%), and S. sonnei (28%). There was a steady increase in the proportion of S. sonnei isolates within the region(p<0.001). The average annual percentage increase (AAPI) in nonsusceptibility was 18.4% (p<0.001) for ciprofloxacin (baseline = 0.3); and 13.2%(p<0.001) for NA (baseline = 3). AAPI nonsusceptibility to ciprofloxacin was 13.3% for S. flexneri (p<0.04); and 39.9% for S. sonnei (p<0.001). Honduras, Dominican Republic, Venezuela, and Chile reported the highest increase in nonsusceptibility to ciprofloxacin among all Shigella isolates. CONCLUSION There is an increasing trend in Shigella nonsusceptibility to ciprofloxacin and NA, including among the most common shigella species, in Latin America. This rise of nonsusceptibility among Shigella species to commonly used treatments such as ciprofloxacin is alarming and threatens the control and management of this currently treatable infection. Improved data quality, collection and reporting is needed in Latin America to respond effectively to the rising trends observed. This includes the need for quality isolate level epidemiological data; molecular data, and data on antibiotic consumption and use.
Collapse
Affiliation(s)
- Hatim F. Sati
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
- * E-mail:
| | - Nienke Bruinsma
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
| | - Marcelo Galas
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
| | - Jenny Hsieh
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
| | - Antonio Sanhueza
- Health Analyses Metrics and Evidence (EIH/HA), Evidence and Intelligence for Action in Health (EIH), Pan American Health Organization, Washington, DC, United States of America
| | - Pilar Ramon Pardo
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
| | - Marcos A. Espinal
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, United States of America
| |
Collapse
|
16
|
Kang H, Wang L, Li Y, Lu Y, Fan W, Bi R, Qian H, Gu B. Dissemination of Multidrug-Resistant Shigella flexneri and Shigella sonnei with Class 1, Class 2, and Atypical Class 1 Integrons in China. Microb Drug Resist 2019; 25:1465-1474. [PMID: 31369341 DOI: 10.1089/mdr.2018.0229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Emergence of multidrug-resistant Shigella, a major causative agent of bacterial dysentery, has generated many concerns not only in China but also worldwide. However, the prevalence of Shigella resistance caused by integron in the nonpopular season of diarrhea is not clear. Materials and Methods: Thirty-one Shigella flexneri and 22 Shigella sonnei samples collected in December 2010 from 10 cities of China were characterized for antimicrobial susceptibility, gene cassettes, widespread of integrons, and pulsed-field gel electrophoresis (PFGE) profile. Results: Multidrug resistance (MDR) was detected in 29 (93.5%) S. flexneri and 20 (90.9%) S. sonnei isolates. Class 1 integrons were detected in 25 (80.6%) S. flexneri and in 13 (59.1%) S. sonnei isolates; class 2 integrons were detected in 26 (83.9%) S. flexneri and in 19 (86.4%) S. sonnei isolates. Interestingly, the atypical class 1 integrons were mostly detected in S. flexneri (45.2%) isolates, whereas in only 1 (4.5%) S. sonnei isolate. DNA sequencing revealed two novel cassette arrays, dfrA5 and aacA4-cmlA, of class 1 integrons in S. flexneri, and dfrA17-aadA5 in S. sonnei isolates. The cassette arrays, dfrA1-sat1-aadA1 of class 2 integron and blaoxa-30-aadA1 of atypical class 1 integron, were also identified. PFGE profiles demonstrated A6 subtype of S. flexneri strains prevalent in Shanghai, Changchun, Jinan, and Changsha; and F6 subtype of S. sonnei prevalent in Jinan, Changchun, and Shanghai. Conclusion: The dissemination of MDR Shigella strains with integrons makes it an increasing public health problem in China. Increased surveillance and the development of adequate prevention strategies are warranted.
Collapse
Affiliation(s)
- Haiquan Kang
- Department of Laboratory Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Lei Wang
- Department of Histology and Embryology, Xuzhou Medical University, Xuzhou, China
| | - Yun Li
- Institute of Clinical Pharmacology, The First Hospital, Peking University, Beijing, China
| | - Yuan Lu
- Institute of Clinical Pharmacology, The First Hospital, Peking University, Beijing, China
| | - Wenting Fan
- Medical Technology School, Xuzhou Medical University, Xuzhou, China
| | - Ruru Bi
- Medical Technology School, Xuzhou Medical University, Xuzhou, China
| | - Huimin Qian
- Department of Acute Infectious Disease Prevention and Control, Jiangsu Provincial Center for Disease Prevention and Control, Nanjing, China
| | - Bing Gu
- Department of Laboratory Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Medical Technology School, Xuzhou Medical University, Xuzhou, China
| |
Collapse
|
17
|
Cohen D, Meron-Sudai S, Bialik A, Asato V, Goren S, Ariel-Cohen O, Reizis A, Hochberg A, Ashkenazi S. Serum IgG antibodies to Shigella lipopolysaccharide antigens - a correlate of protection against shigellosis. Hum Vaccin Immunother 2019; 15:1401-1408. [PMID: 31070988 DOI: 10.1080/21645515.2019.1606971] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Shigella is a leading cause of diarrhea among children globally and of diarrheal deaths among children under 5 years of age in low- and middle-income countries. To date, no licensed Shigella vaccine exists. We review evidence that serum IgG antibodies to Shigella LPS represent a good correlate of protection against shigellosis; this could support the process of development and evaluation of Shigella vaccine candidates. Case-control and cohort studies conducted among Israeli soldiers serving under field conditions showed significant serotype-specific inverse associations between pre-exposure serum IgG antibodies to Shigella LPS and shigellosis incidence. The same serum IgG fraction showed a dose-response relationship with the protective efficacy attained by vaccine candidates tested in phase III trials of young adults and children aged 1-4 years and in Controlled Human Infection Model studies and exhibited mechanistic protective capabilities. Identifying a threshold level of these antibodies associated with protection can promote the development of an efficacious vaccine for infants and young children.
Collapse
Affiliation(s)
- Dani Cohen
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Shiri Meron-Sudai
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Anya Bialik
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Valeria Asato
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Sophy Goren
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Ortal Ariel-Cohen
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Arava Reizis
- a School of Public Health, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv Israel
| | - Amit Hochberg
- b Newborn and Neonatal Care Department , Hillel Yaffe Medical Center , Hadera , Israel
| | - Shai Ashkenazi
- c Adelson School of Medicine , Ariel University, and Schneider Children's Medical Center , Israel
| |
Collapse
|
18
|
Williams PCM, Berkley JA. Guidelines for the treatment of dysentery (shigellosis): a systematic review of the evidence. Paediatr Int Child Health 2018; 38:S50-S65. [PMID: 29790845 PMCID: PMC6021764 DOI: 10.1080/20469047.2017.1409454] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/04/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Shigella remains the primary cause of diarrhoea in paediatric patients worldwide and accounts for up to 40,000 deaths per year. Current guidelines for the treatment of shigellosis are based on data which are over a decade old. In an era of increasing antimicrobial resistance, an updated review of the appropriate empirical therapy for shigellosis in children is necessary, taking into account susceptibility patterns, cost and the risk of adverse events. METHODS A systematic review of the current published literature on the treatment of shigella dysentery was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS The initial search produced 131 results, of which nine studies met the inclusion criteria. The quality of the studies was assessed as per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. International guidelines were also reviewed. There is a lack of current research regarding the clinical treatment of shigellosis in paediatric and adult patients, despite rising antimicrobial resistance worldwide. In particular, there is a lack of studies assessing the non-susceptibility of community-acquired strains, with almost all published research pertaining to microbiological data from hospital-based settings. DISCUSSION Current WHO guidelines support the use of fluoroquinolones (first-line), β-lactams (second-line) and cephalosporins (second-line) which accords with currently available evidence and other international guidelines, and there is no strong evidence for changing this guidance. Azithromycin is appropriate as a second-line therapy in regions where the rate of non-susceptibility of ciprofloxacin is known to be high, and research suggests that, from a cardiac point of view, azithromycin is safer than other macrolide antibiotics. Cefixime is also a reasonable alternative, although its use must be weighed against the risk of dissemination of extended-spectrum β-lactamase-producing organisms.
Collapse
Affiliation(s)
| | - James A. Berkley
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition Network (CHAIN), Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, The University of Oxford, Oxford, UK
| |
Collapse
|
19
|
Riddle M, Chen W, Kirkwood C, MacLennan C. Update on vaccines for enteric pathogens. Clin Microbiol Infect 2018; 24:1039-1045. [DOI: 10.1016/j.cmi.2018.06.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 12/12/2022]
|
20
|
Prevalence and characterisation of third-generation cephalosporin-resistant Shigella flexneri isolates from Jiangsu Province, China, 2013-2015. J Glob Antimicrob Resist 2018; 15:283-287. [PMID: 30144637 DOI: 10.1016/j.jgar.2018.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 07/18/2018] [Accepted: 08/14/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the prevalence of Shigella flexneri resistance to third-generation cephalosporins (3GCs) and to characterise the underlying resistance mechanisms. METHODS A total of 282 S. flexneri strains isolated in 2013-2015 in Jiangsu Province, China, were identified, serotyped and analysed for their susceptibility to 3GCs. The blaTEM, blaSHV, blaOXA-1-like and blaCTX-M-type extended-spectrum β-lactamase (ESBL) genes were amplified and sequenced by PCR. RESULTS Of the 282 S. flexneri strains, 97 (34.4%) were resistant to cefotaxime, from which 68 (24.1%) were also resistant to ceftazidime. ESBL genes were detected in 73/97 isolates (75.3%), of which 66/73 (90.4%) showed resistance to 3GCs. Of the 73 ESBL-positive isolates, 32 (43.8%) were positive for CTX-M-1 group (17 for CTX-M-55, 4 for CTX-M-3, 1 for CTX-M-15, 3 for CTX-M-79 and 7 for CTX-M-123), 31 (42.5%) were positive for CTX-M-9 group (29 for CTX-M-14, 1 for CTX-M-24 and 1 for CTX-M-27), 25 (34.2%) were positive for TEM-types (21 for TEM-1 and 4 for TEM-1b) and 1 (1.4%) was positive for SHV-type (SHV-12); none were positive for CTX-M-2 group, CTX-M-8 group and OXA-type. CONCLUSION ESBLs play an important role in Shigella resistance to 3GCs. CTX-M-14 and CTX-M-55 appeared to be the dominant ESBLs in 13 cities of Jiangsu Province. Therefore, it is time to regularly monitor resistance of S. flexneri to 3GCs and to take appropriate measures to manage this problem.
Collapse
|
21
|
Williams E, Lew TE, Fuller A, Spelman DW, Jenney AW. A case of multi-drug resistant ESBL-producing Shigella sonnei acute acalculous cholecystitis and gastroenteritis in a returned traveller. J Travel Med 2018; 25:5088401. [PMID: 30169854 DOI: 10.1093/jtm/tay029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 07/23/2018] [Indexed: 01/13/2023]
Abstract
The first case of Shigella-associated acalculous cholecystitis is described. A 27-year-old woman presented to hospital with diarrhoea and acute acalculous cholecystitis one day after return to Australia from Vietnam. Her feces culture grew multi-drug resistant ESBL-producing Shigella sonnei and she improved with antimicrobial therapy and intravenous fluids.
Collapse
Affiliation(s)
- Eloise Williams
- Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | | | - Andrew Fuller
- Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Denis W Spelman
- Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Adam W Jenney
- Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Shahin K, Bouzari M. Bacteriophage application for biocontrolling Shigella flexneri in contaminated foods. JOURNAL OF FOOD SCIENCE AND TECHNOLOGY 2018; 55:550-559. [PMID: 29391619 PMCID: PMC5785380 DOI: 10.1007/s13197-017-2964-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Revised: 10/24/2017] [Accepted: 11/02/2017] [Indexed: 12/31/2022]
Abstract
Shigellosis (bacillary dysentery) is an acute enteric infection caused by members of Shigella genus. It causes annual deaths of approximately five million children in developing countries. Among Shigella spp., S. flexneri causes more serious forms of dysentery than other Shigella species. Due to the appearance of multidrug-resistant strains of Shigella spp., it is necessary to find alternative antimicrobial agents. The aims of this study were the isolation of a novel species-specific phage against S. flexneri and to evaluate its potential and efficacy for biocontrolling of S. flexneri in foods. Shigella flexneri PTCC 1234 was used as the host strain for bacteriophage isolation from waste water. A lytic phage of the Siphoviridae family was isolated and designated as vB_SflS-ISF001. The phage activity remained at high levels after 1 h of incubation at - 20 to 50 °C and was fairly stable for 1 h at pH values ranging from 7 to 9. The latent period and burst size were approximately 20 min and 53 ± 4 phages per host cell, respectively. Raw and cooked chicken breast were inoculated with a predetermined amount of S. flexneri and subjected to biocontrol test. The results showed that using vB_SflS-ISF001 phage led to more than two logs reduction in the count of viable S. flexneri. It was demonstrated that using vB_SflS-ISF001 phage is of high potential for developing an alternative strategy against S. flexneri contamination in foodstuffs.
Collapse
Affiliation(s)
- Khashayar Shahin
- Department of Biology, Faculty of Sciences, University of Isfahan, Isfahan, 81746-73441 Iran
| | - Majid Bouzari
- Department of Biology, Faculty of Sciences, University of Isfahan, Isfahan, 81746-73441 Iran
| |
Collapse
|
23
|
Rajpara N, Nair M, Chowdhury G, Mukhopadhyay AK, Ramamurthy T, Niyogi SK, Bhardwaj AK. Molecular analysis of multidrug resistance in clinical isolates of Shigella spp. from 2001-2010 in Kolkata, India: role of integrons, plasmids, and topoisomerase mutations. Infect Drug Resist 2018; 11:87-102. [PMID: 29391815 PMCID: PMC5769595 DOI: 10.2147/idr.s148726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To understand the genetic basis of high drug resistance in Shigella, 95 clinical isolates of Shigella spp. (2001-2010) were obtained from the Infectious Diseases Hospital, Kolkata, India. Ninety-three isolates were resistant to three or more antibiotics. Resistance to nalidixic acid, trimethoprim, streptomycin, and co-trimoxazole was most common in this population. Dendrogram analysis showed that S. sonnei strains were more clonally related when compared to the other Shigella species. The role of mobile genetic elements and chromosome-borne resistance factors was analyzed in detail. Integron analysis indicated the preponderance of class 2 and atypical class 1 integrons in that population. Typical class 1 integron was present in only one S. sonnei isolate and harbored trimethoprim resistance-encoding gene dfrV, while atypical class 1 integrons harbored dfrA1-aadA or blaOXA-aadA gene cassettes responsible for resistance to trimethoprim, aminoglycosides, and β-lactams. Class 2 integrons harbored either dfrA1-sat-aadA or dfrA1-sat gene cassettes. Most importantly, a novel gene cassette array InsE-InsO-dfrA1-sat was found in class 2 integron of S. sonnei NK4846. Many of the resistance traits for antibiotics such as trimethoprim, co-trimoxazole, kanamycin, ampicillin, and tetracycline were transferred from parent Shigella isolates to recipient Escherichia coli during conjugation, establishing the role of plasmids in horizontal transfer of resistance genes. Multiple mutations such as S80→I, S83→L, and D87→G/N/Y in quinolone resistance determining regions of topoisomerases from the representative quinolone-resistant isolates could explain the spectrum of minimal inhibitory concentration values for various quinolones. To the best of our knowledge, this is the first comprehensive report that describes the contribution of mobile (plasmids, integrons, and quinolone resistance genes named qnr) and innate genetic elements (mutations in topoisomerases) in determining the resistance phenotype of all the four species of Shigella over a span of ten years.
Collapse
Affiliation(s)
- Neha Rajpara
- Department of Human Health and Diseases, Indian Institute of Advanced Research, Koba Institutional Area, Gandhinagar.,Department of Microbiology and Biotechnology Centre, Maharaja Sayaji Rao University of Baroda, Vadodara, Gujarat
| | - Mrinalini Nair
- Department of Microbiology and Biotechnology Centre, Maharaja Sayaji Rao University of Baroda, Vadodara, Gujarat
| | - Goutam Chowdhury
- Department of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata
| | - Asish K Mukhopadhyay
- Department of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata
| | - Thandavarayan Ramamurthy
- Center for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India
| | - Swapan Kumar Niyogi
- Department of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata
| | - Ashima Kushwaha Bhardwaj
- Department of Human Health and Diseases, Indian Institute of Advanced Research, Koba Institutional Area, Gandhinagar
| |
Collapse
|
24
|
Tickell KD, Brander RL, Atlas HE, Pernica JM, Walson JL, Pavlinac PB. Identification and management of Shigella infection in children with diarrhoea: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e1235-e1248. [PMID: 29132613 PMCID: PMC5695759 DOI: 10.1016/s2214-109x(17)30392-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 08/22/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shigella infections are a leading cause of diarrhoeal death among children in low-income and middle-income countries. WHO guidelines reserve antibiotics for treating children with dysentery. Reliance on dysentery for identification and management of Shigella infection might miss an opportunity to reduce Shigella-associated morbidity and mortality. We aimed to systematically review and evaluate Shigella-associated and dysentery-associated mortality, the diagnostic value of dysentery for the identification of Shigella infection, and the efficacy of antibiotics for children with Shigella or dysentery, or both. METHODS We did three systematic reviews (for mortality, diagnostic value, and antibiotic treatment of Shigella and dysentery), and meta-analyses where appropriate, of studies in resource-limited settings. We searched MEDLINE, Embase, and LILACS database for studies published before Jan 1, 2017, in English, French, and Spanish. We included studies of human beings with diarrhoea and accepted all study-specific definitions of dysentery. For the mortality and diagnostic value searches, we excluded studies that did not include an effect estimate or data necessary to calculate this estimate. The search for treatment included only randomised controlled trials that were done after Jan 1, 1980, and assessed antibiotics in children (aged <18 years) with dysentery or laboratory-confirmed Shigella. We extracted or calculated odds ratios (ORs) and 95% CIs for relative mortality and did random-effects meta-analysis to arrive at pooled ORs. We calculated 95% CIs assuming a binomial distribution and did random-effects meta-regression of log-transformed sensitivity and specificity estimates for diagnostic value. We assessed the heterogeneity of papers included in these meta-analyses using the I2 statistic and evaluated publication bias using funnel plots. This review is registered with PROSPERO (CRD42017063896). FINDINGS 3649 papers were identified and 60 studies were included for analyses: 13 for mortality, 27 for diagnostic value, and 20 for treatment. Shigella infection was associated with mortality (pooled OR 2·8, 95% CI 1·6-4·8; p=0·000) whereas dysentery was not associated with mortality (1·3, 0·7-2·3; p=0·37). Between 1977 and 2016, dysentery identified 1·9-85·9% of confirmed Shigella infections, with sensitivity decreasing over time (p=0·04). Ten (50%) of 20 included antibiotic trials were among children with dysentery, none were placebo-controlled, and two (10%) evaluated antibiotics no longer recommended for acute infectious diarrhoea. Ciprofloxacin showed superior microbiological, but not clinical, effectiveness compared with pivmecillinam, and no superior microbiological and clinical effectiveness compared with gatifloxacin. Substantial heterogeneity was reported for meta-analyses of the Shigella-associated mortality studies (I2=78·3%) and dysentery-associated mortality studies (I2=73·2%). Too few mortality studies were identified to meaningfully test for publication bias. No evidence of publication bias was found in this analysis of studies of diagnostic value. INTERPRETATION Current WHO guidelines appear to manage dysentery effectively, but might miss opportunities to reduce mortality among children infected with Shigella who present without bloody stool. Further studies should quantify potential decreases in mortality and morbidity associated with antibiotic therapy for children with non-dysenteric Shigella infection. FUNDING Bill & Melinda Gates Foundation and the Center for AIDS Research International Core.
Collapse
Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Rebecca L Brander
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Hannah E Atlas
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jeffrey M Pernica
- Division of Infectious Disease, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
25
|
Tribble DR. Resistant pathogens as causes of traveller's diarrhea globally and impact(s) on treatment failure and recommendations. J Travel Med 2017; 24:S6-S12. [PMID: 28520997 PMCID: PMC5731445 DOI: 10.1093/jtm/taw090] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND : Diarrhea is a frequent clinical syndrome affecting international travellers. Bacterial etiologic agents have a long history of emergent antimicrobial resistance against commonly used antibiotics. Current approaches applying first-line antimicrobial therapy are being challenged by increasingly resistant organisms. This review summarizes recent epidemiological and clinical evidence of antibiotic resistance among enteropathogens causing traveller's diarrhea and the subsequent impact on current treatment recommendations. METHODS : The PubMed database was systemically searched for articles related to antibiotic susceptibility and diarrheal pathogens. RESULTS : Antibiotic resistance related to travellers' diarrhea has increased in recent years. Most notably, fluoroquinolone resistance has expanded from the Campylobacter -associated cases well documented in Southeast Asia in the 1990s to widespread occurrence, as well as increases among other common bacterial enteropathogens including, enterotoxigenic and enteroaggregative Escherichia coli , Shigella and non-typhoidal Salmonella . Multidrug resistance among enteropathogenic Enterobacteriacae and Campylobacter species create further challenges with the selection of empiric therapy. Treatment failures requiring early use of alternative agents, as well as delayed recovery comparable to placebo rates emphasize the impact of antimicrobial resistance on effective treatment. CONCLUSIONS : Although there are limitations in the available data, the increasing antibiotic resistance and adverse impact on clinical outcome require continued surveillance and reconsideration of practice guidelines.
Collapse
Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-5119, USA
| |
Collapse
|
26
|
Riddle MS, Kaminski RW, Di Paolo C, Porter CK, Gutierrez RL, Clarkson KA, Weerts HE, Duplessis C, Castellano A, Alaimo C, Paolino K, Gormley R, Gambillara Fonck V. Safety and Immunogenicity of a Candidate Bioconjugate Vaccine against Shigella flexneri 2a Administered to Healthy Adults: a Single-Blind, Randomized Phase I Study. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2016; 23:908-917. [PMID: 27581434 PMCID: PMC5139601 DOI: 10.1128/cvi.00224-16] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/01/2016] [Indexed: 11/20/2022]
Abstract
Several candidate vaccines against Shigella spp. are in development, but the lack of a clear correlate of protection from challenge with the induction of adequate immune responses among the youngest age groups in the developing world has hampered Shigella vaccine development over the past several decades. Bioconjugation technology, exploited here for an Shigella flexneri 2a candidate vaccine, offers a novel and potentially cost-effective way to develop and produce vaccines against a major pathogen of global health importance. Flexyn2a, a novel S. flexneri 2a bioconjugate vaccine made of the polysaccharide component of the S. flexneri 2a O-antigen, conjugated to the exotoxin protein A of Pseudomonas aeruginosa (EPA), was evaluated for safety and immunogenicity among healthy adults in a single-blind, phase I study with a staggered randomization approach. Thirty subjects (12 receiving 10 μg Flexyn2a, 12 receiving Flexyn2a with aluminum adjuvant, and 6 receiving placebo) were administered two injections 4 weeks apart and were followed for 168 days. Flexyn2a was well-tolerated, independently of the adjuvant and number of injections. The Flexyn2a vaccine elicited statistically significant S. flexneri 2a lipopolysaccharide (LPS)-specific humoral responses at all time points postimmunization in all groups that received the vaccine. Elicited serum antibodies were functional, as evidenced by bactericidal activity against S. flexneri 2a. The bioconjugate candidate vaccine Flexyn2a has a satisfactory safety profile and elicited a robust humoral response to S. flexneri 2a LPS with or without inclusion of an adjuvant. Moreover, the bioconjugate also induced functional antibodies, showing the technology's features in producing a promising candidate vaccine. (This study has been registered at ClinicalTrials.gov under registration no. NCT02388009.).
Collapse
Affiliation(s)
- Mark S Riddle
- Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Robert W Kaminski
- Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | - Chad K Porter
- Naval Medical Research Center, Silver Spring, Maryland, USA
| | | | | | - Hailey E Weerts
- Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | - Amy Castellano
- Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | | | - Robert Gormley
- Naval Medical Research Center, Silver Spring, Maryland, USA
| | | |
Collapse
|
27
|
Zhang C, Zhang R, Yu Q, Chu X, Sun J, Liu Q. Decreased Susceptibility to Azithromycin Among Clinical Shigella Isolates from China. Microb Drug Resist 2016; 23:596-601. [PMID: 27841958 DOI: 10.1089/mdr.2016.0134] [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] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to detect the decreased susceptibility to azithromycin (DSA) and associated mechanisms in Shigella from China. Three hundred and ninety-two Shigella isolates, including 134 Shigella flexneri and 258 Shigella sonnei isolates, were examined for minimum inhibitory concentrations (MICs) and zone sizes to azithromycin by broth microdilution and disk diffusion methods, respectively. The MICs were compared with corresponding zone diameters to find whether there was uniformity between both tests. Twelve macrolide-resistant genes located on mobile elements were determined for the DSA isolates by PCR, and chromosomal efflux pump activity was analyzed using Phe-Arg-β-naphthylamide inhibition test and quantitative real-time PCR. Shigella isolates displayed MICs of 0.125-512 μg/ml and zone sizes of 6-26 mm against azithromycin. There were 80 (20.4%) isolates to be DSA. No significant difference was found between the DSA rates of S. flexneri and S. sonnei isolates (p = 0.052). There was an intimate relativity between MICs and zone diameters (p < 0.001). Only the plasmid-borne mphA conferring high-level DSA was detected in 55.0% (44/80) DSA-Shigella isolates. This study highlighted the prevalence of DSA-Shigella and mphA in the region studied. Clinical laboratories and clinicians should pay attention to the elevated azithromycin MICs in Shigella spp.
Collapse
Affiliation(s)
- Chuanling Zhang
- 1 Department of Clinical Laboratory, Zhejiang Xiaoshan Hospital , Hangzhou, China
| | - Rulin Zhang
- 2 Department of Clinical Laboratory, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai, China
| | - Qi Yu
- 2 Department of Clinical Laboratory, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai, China
| | - Xu Chu
- 1 Department of Clinical Laboratory, Zhejiang Xiaoshan Hospital , Hangzhou, China
| | - Jingyong Sun
- 3 Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China
| | - Qingzhong Liu
- 2 Department of Clinical Laboratory, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai, China
| |
Collapse
|