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Vosseteig A, Huang T, Jones P. Modified Sequential Organ Failure Assessment score for predicting mortality in emergency department patients with sepsis. Emerg Med Australas 2023; 35:504-509. [PMID: 36754067 DOI: 10.1111/1742-6723.14180] [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: 07/26/2022] [Revised: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Several scoring systems have been proposed for EDs to identify patients at increased risk of mortality from sepsis. The modified Sequential Organ Failure Assessment (mSOFA) score, proposed in 2019, demonstrated a high negative predictive value. We aimed to validate mSOFA and compare its accuracy for predicting 30-day mortality to the simple bedside score, quick SOFA (qSOFA). METHODS Over 1 month in 2018, consecutive patients with suspected sepsis were prospectively identified. A retrospective chart review was conducted to calculate both the mSOFA and qSOFA scores for these patients. The primary outcome was 30-day mortality. RESULTS There were 252 patients with suspected sepsis identified over the study period. Thirty-day mortality was 13/39 (33.3%) for those with a positive mSOFA and 15/211 (7.1%) for those with a negative mSOFA score. Sensitivity was 46.4% (95% confidence interval [CI] 27.5-66.1%), specificity 88.3% (95% CI 83.3-92.2%), positive likelihood ratio 3.96 (95% CI 2.32-6.78), negative likelihood ratio 0.61 (95% CI 0.43-0.86). The area under the curve (AUC) was 0.74 (95% CI 0.64-0.85). qSOFA sensitivity was 39.3% (95% CI 21.5-59.4%), specificity 91.9% (95% CI 87.5-95.1%), positive likelihood ratio 4.85 (95% CI 2.56-9.18) and negative likelihood ratio 0.66 (95% CI 0.49-0.89). The AUC for qSOFA was 0.81 (95% CI 0.73-0.88). The difference in the AUC was -0.07 (95% CI -0.18 to 0.05), P = 0.25. CONCLUSIONS In the present study, neither mSOFA nor qSOFA was adequately sensitive for predicting 30-day mortality, although both scores were highly specific and their overall accuracy was similar. The added complexity of the mSOFA without a significant increase in discriminative ability makes it unlikely to replace qSOFA in the ED setting.
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Affiliation(s)
- Anna Vosseteig
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Emergency Department, Tauranga Hospital, Tauranga, New Zealand
| | - Tiffany Huang
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Brinkworth JF, Shaw JG. On race, human variation, and who gets and dies of sepsis. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022. [PMCID: PMC9544695 DOI: 10.1002/ajpa.24527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jessica F. Brinkworth
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
- Department of Evolution, Ecology and Behavior University of Illinois Urbana‐Champaign Urbana Illinois USA
| | - J. Grace Shaw
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
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Rogan A, Lockett J, Peckler B, Robinson B, Raymond N. Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study. Emerg Med Australas 2021; 34:417-427. [PMID: 34889063 DOI: 10.1111/1742-6723.13911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis. METHODS This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi-structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio-recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software. RESULTS Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail. CONCLUSION ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies.
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Affiliation(s)
- Alice Rogan
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Jessica Lockett
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brad Peckler
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brian Robinson
- School of Nursing and Midwifery, Victoria University of Wellington, Wellington, New Zealand
| | - Nigel Raymond
- Infection Service and General Medicine Department, Wellington Regional Hospital, Wellington, New Zealand
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Slim MAM, Lala HM, Barnes N, Martynoga RA. Māori health outcomes in an intensive care unit in Aotearoa New Zealand. Anaesth Intensive Care 2021; 49:292-300. [PMID: 34154375 DOI: 10.1177/0310057x21989715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Māori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Māori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Māori. Our study aimed to describe Māori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Māori were over-represented relative to the general population. Compared to non-Māori, Māori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Māori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Māori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Māori risk for critical illness. There was no difference in mortality outcomes.
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Affiliation(s)
- M Atif Mohd Slim
- Department of Critical Care, Waikato Hospital, Hamilton, New Zealand
| | - Hamish M Lala
- Department of Critical Care, Waikato Hospital, Hamilton, New Zealand
| | - Nicholas Barnes
- Department of Critical Care, Waikato Hospital, Hamilton, New Zealand
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5
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Challenges to Reporting the Global Trends in the Epidemiology of ICU-Treated Sepsis and Septic Shock. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00749-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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6
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Fleischmann-Struzek C, Mellhammar L, Rose N, Cassini A, Rudd KE, Schlattmann P, Allegranzi B, Reinhart K. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. Intensive Care Med 2020; 46:1552-1562. [PMID: 32572531 PMCID: PMC7381468 DOI: 10.1007/s00134-020-06151-x] [Citation(s) in RCA: 316] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Purpose To investigate the global burden of sepsis in hospitalized adults by updating and expanding a systematic review and meta-analysis and to compare findings with recent Institute for Health Metrics and Evaluation (IHME) sepsis estimates. Methods Thirteen electronic databases were searched for studies on population-level sepsis incidence defined according to clinical criteria (Sepsis-1, -2: severe sepsis criteria, or sepsis-3: sepsis criteria) or relevant ICD-codes. The search of the original systematic review was updated for studies published 05/2015–02/2019 and complemented by a search targeting low- or middle-income-country (LMIC) studies published 01/1979–02/2019. We performed a random-effects meta-analysis with incidence of hospital- and ICU-treated sepsis and proportion of deaths among these sepsis cases as outcomes. Results Of 4746 results, 28 met the inclusion criteria. 21 studies contributed data for the meta-analysis and were pooled with 30 studies from the original meta-analysis. Pooled incidence was 189 [95% CI 133, 267] hospital-treated sepsis cases per 100,000 person-years. An estimated 26.7% [22.9, 30.7] of sepsis patients died. Estimated incidence of ICU-treated sepsis was 58 [42, 81] per 100,000 person-years, of which 41.9% [95% CI 36.2, 47.7] died prior to hospital discharge. There was a considerably higher incidence of hospital-treated sepsis observed after 2008 (+ 46% compared to the overall time frame). Conclusions Compared to results from the IHME study, we found an approximately 50% lower incidence of hospital-treated sepsis. The majority of studies included were based on administrative data, thus limiting our ability to assess temporal trends and regional differences. The incidence of sepsis remains unknown for the vast majority of LMICs, highlighting the urgent need for improved epidemiological sepsis surveillance. Electronic supplementary material The online version of this article (10.1007/s00134-020-06151-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - L Mellhammar
- Division of Infection Medicine, Department of Clinical Sciences, University of Lund, Lund, Sweden
| | - N Rose
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - A Cassini
- Infection Prevention and Control Hub, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - K E Rudd
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - P Schlattmann
- Institute for Medical Statistics, Computer Science and Data Science, Jena University Hospital, Jena, Germany
| | - B Allegranzi
- Infection Prevention and Control Hub, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - K Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany. .,Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany. .,Institute of Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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Chao WC, Wang CY, Hsu BC, Lin CH, Huang WN, Chen YH, Wu CL, Chen HH. Factors associated with sepsis risk in immune-mediated inflammatory diseases receiving tumor necrosis factor inhibitors: a nationwide study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20929208. [PMID: 32595776 PMCID: PMC7298427 DOI: 10.1177/1759720x20929208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Risk factors for sepsis have not been assessed in patients receiving tumor
necrosis factor-alpha inhibitors (TNFi) for immune-mediated inflammatory
diseases (IMIDs) who are vulnerable to serious/hospitalized infections. Methods: Data from 2003–2017 were obtained from Taiwan’s National Health Insurance
Research Database to identify patients receiving TNFi, including etanercept,
adalimumab, and golimumab, for IMIDs including rheumatoid arthritis (RA),
ankylosing spondylitis (AS), psoriasis (PsO), psoriatic arthritis (PsA),
Crohn’s disease (CD), and ulcerative colitis (UC). To investigate risk
factors for sepsis, we used the Sepsis-3 definition and calculated hazard
ratios (HRs) with 95% confidence intervals (CIs) using Cox regression
analysis. Results: There were 17,764 patients (mean age 49.3 ± 14.3 years; females, 57.6%)
receiving TNFi for IMIDs, including RA (58.6%), AS (19.1%), PsO (15.1%), PsA
(2.5%), CD (3.0%), and UC (1.7%). The overall incidence rate of sepsis was
1088 per 100,000 person-years. After adjustment for potential confounders,
recent sepsis within 3 months before TNFi initiation (HR, 2.35; 95% CI,
1.73–3.20), CD (HR, 3.36; 95% CI 2.11–5.34; reference group: AS) and
glucocorticoid use (prednisolone-equivalent dose, mg/day HR, 1.05; 95% CI,
1.05–1.06) were associated with the risk of sepsis. Intriguingly, golimumab
users appeared to have a lower risk of sepsis compared with etanercept users
(HR, 0.56; 95% CI, 0.38–0.83). In addition, socioeconomic status, including
urbanization level and insured amount, was associated with sepsis in a
dose-response manner. Conclusions: Recent sepsis, CD, concomitant glucocorticoid use, and low socioeconomic
status, which were associated with an increased risk of sepsis, are crucial
for individualized risk management plans.
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Affiliation(s)
- Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Bo-Chueh Hsu
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung
| | - Wen-Nan Huang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
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Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study. PLoS One 2020; 15:e0227752. [PMID: 31929577 PMCID: PMC6957188 DOI: 10.1371/journal.pone.0227752] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 12/27/2019] [Indexed: 01/08/2023] Open
Abstract
Purpose To determine the trends of infection sites and outcome of sepsis using a national population-based database. Materials and methods Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality. Results During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%). Conclusions The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.
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Recognition, response and outcomes of sepsis: A dual site retrospective observational study. Int Emerg Nurs 2019; 46:100782. [PMID: 31324537 DOI: 10.1016/j.ienj.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 04/05/2019] [Accepted: 06/05/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To describe clinical recognition, response and outcomes of patients with sepsis. METHODS A retrospective, observational study was undertaken at two hospitals. Inclusion criteria were: adult patients admitted via the Emergency Department (ED) between 1 January and 30 April 2014 allocated a primary ICD-10-AM discharge from hospital code related to sepsis. Recognition of sepsis was considered based on the presence of clinical documentation that reflects the Sepsis Kills criteria being met. Response to sepsis was considered based on the presence of clinical documentation where the patient received a response consistent with the 'Sepsis Six' strategies. Outcomes pertained to response to sepsis (e.g. time to antibiotics) and ED measures (e.g. time to be seen, ED length of stay). Sub-group analysis considered location where sepsis was recognised (ED/ward). RESULT In total, 96 patients met the inclusion criteria; most were admitted under general medicine (37%) followed by intensive care (18%). Sepsis was recognised in the ED for most patients (n = 64), with a history of fevers/rigors the most common (60%) indication of infection. Regarding response and ED outcomes for this group, the median time from triage nurse assessment i) to being seen by the treating clinician was 19 min; ii) to sepsis recognition was 27 min; and iii) to antibiotics was 181 min; 35% received antibiotics within 60 min from recognition. Those recognised in the ED had a longer ED stay than those where sepsis was recognised on the ward (336 min vs. 225 min, p = 0.013). CONCLUSIONS Sepsis can develop at various stages throughout the patient's journey. In this small sample, ED recognition was associated with longer ED stay, likely due to more interventions. Whilst guidelines recommend antibiotics be administered within 60 min of triage, this was not achieved for most patients. Given the dynamic nature of sepsis, future indicators may focus on time from recognition rather than time from triage.
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Namikawa H, Yamada K, Sakiyama A, Imoto W, Yamairi K, Shibata W, Yoshii N, Niki M, Nakaie K, Oinuma KI, Tsubouchi T, Niki M, Tochino Y, Takemoto Y, Kaneko Y, Shuto T, Kakeya H. Clinical characteristics of bacteremia caused by hypermucoviscous Klebsiella pneumoniae at a tertiary hospital. Diagn Microbiol Infect Dis 2019; 95:84-88. [PMID: 31256940 DOI: 10.1016/j.diagmicrobio.2019.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/06/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023]
Abstract
This study aimed to assess the predictive factors of bacteremia due to hypermucoviscous Klebsiella pneumoniae (hvKP), as well as the mortality. The medical records of 114 patients with K. pneumoniae bacteremia who were divided into the hvKP (n = 24) and non-hvKP (n = 90) groups and were retrospectively reviewed. The male-to-female ratio, age, and underlying disease did not differ between the 2 groups. Mortality was higher among patients in the hvKP bacteremia group than in the non-hvKP bacteremia group (29.2% vs 6.7%). Multivariate analysis showed that the independent predictors associated with hvKP bacteremia were abscess (P = 0.01) and no antibiotic exposure (P = 0.02); thus, early assessment of these conditions is important. For patients with a history of abscess and no antibiotic exposure, it is necessary to administer treatment while keeping the risk of hvKP in mind.
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Affiliation(s)
- Hiroki Namikawa
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan; Department of Medical Education and General Practice, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Koichi Yamada
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Arata Sakiyama
- Department of Bacteriology, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Waki Imoto
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Kazushi Yamairi
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Wataru Shibata
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Naoko Yoshii
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Makoto Niki
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Kiyotaka Nakaie
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Ken-Ichi Oinuma
- Department of Bacteriology, Osaka City University, Graduate School of Medicine, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Taishi Tsubouchi
- Department of Bacteriology, Osaka City University, Graduate School of Medicine, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Mamiko Niki
- Department of Bacteriology, Osaka City University, Graduate School of Medicine, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Yoshihiro Tochino
- Department of Medical Education and General Practice, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Yasuhiko Takemoto
- Department of Medical Education and General Practice, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Yukihiro Kaneko
- Department of Bacteriology, Osaka City University, Graduate School of Medicine, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Taichi Shuto
- Department of Medical Education and General Practice, Osaka City University, Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Osaka City University, Graduate School of Medicine, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan; Research Center for Infectious Disease Sciences, Osaka City University, Graduate School of Medicine, Osaka, Japan.
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