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Jiang JH, Cameron DR, Nethercott C, Aires-de-Sousa M, Peleg AY. Virulence attributes of successful methicillin-resistant Staphylococcus aureus lineages. Clin Microbiol Rev 2023; 36:e0014822. [PMID: 37982596 PMCID: PMC10732075 DOI: 10.1128/cmr.00148-22] [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] [Indexed: 11/21/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of severe and often fatal infections. MRSA epidemics have occurred in waves, whereby a previously successful lineage has been replaced by a more fit and better adapted lineage. Selection pressures in both hospital and community settings are not uniform across the globe, which has resulted in geographically distinct epidemiology. This review focuses on the mechanisms that trigger the establishment and maintenance of current, dominant MRSA lineages across the globe. While the important role of antibiotic resistance will be mentioned throughout, factors which influence the capacity of S. aureus to colonize and cause disease within a host will be the primary focus of this review. We show that while MRSA possesses a diverse arsenal of toxins including alpha-toxin, the success of a lineage involves more than just producing toxins that damage the host. Success is often attributed to the acquisition or loss of genetic elements involved in colonization and niche adaptation such as the arginine catabolic mobile element, as well as the activity of regulatory systems, and shift metabolism accordingly (e.g., the accessory genome regulator, agr). Understanding exactly how specific MRSA clones cause prolonged epidemics may reveal targets for therapies, whereby both core (e.g., the alpha toxin) and acquired virulence factors (e.g., the Panton-Valentine leukocidin) may be nullified using anti-virulence strategies.
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Affiliation(s)
- Jhih-Hang Jiang
- Department of Microbiology, Infection Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David R. Cameron
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Cara Nethercott
- Department of Microbiology, Infection Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Marta Aires-de-Sousa
- Laboratory of Molecular Genetics, Institutode Tecnologia Químicae Biológica António Xavier (ITQB-NOVA), Universidade Nova de Lisboa, Oeiras, Portugal
- Escola Superior de Saúde da Cruz Vermelha Portuguesa-Lisboa (ESSCVP-Lisboa), Lisbon, Portugal
| | - Anton Y. Peleg
- Department of Microbiology, Infection Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Centre to Impact Antimicrobial Resistance, Monash University, Clayton, Melbourne, Victoria, Australia
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Bai Z, Chen M, Lin Q, Ye Y, Fan H, Wen K, Zeng J, Huang D, Mo W, Lei Y, Liao Z. Identification of Methicillin-Resistant Staphylococcus Aureus From Methicillin-Sensitive Staphylococcus Aureus and Molecular Characterization in Quanzhou, China. Front Cell Dev Biol 2021; 9:629681. [PMID: 33553185 PMCID: PMC7858276 DOI: 10.3389/fcell.2021.629681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
To distinguish Methicillin-Resistant Staphylococcus aureus (MRSA) from Methicillin-Sensitive Staphylococcus aureus (MSSA) in the protein sequences level, test the susceptibility to antibiotic of all Staphylococcus aureus isolates from Quanzhou hospitals, define the virulence factor and molecular characteristics of the MRSA isolates. MRSA and MSSA Pfam protein sequences were used to extract feature vectors of 188D, n-gram and 400D. Weka software was applied to classify the two Staphylococcus aureus and performance effect was evaluated. Antibiotic susceptibility testing of the 81 Staphylococcus aureus was performed by the Mérieux Microbial Analysis Instrument. The 65 MRSA isolates were characterized by Panton-Valentine leukocidin (PVL), X polymorphic region of Protein A (spa), multilocus sequence typing test (MLST), staphylococcus chromosomal cassette mec (SCCmec) typing. After comparing the results of Weka six classifiers, the highest correctly classified rates were 91.94, 70.16, and 62.90% from 188D, n-gram and 400D, respectively. Antimicrobial susceptibility test of the 81 Staphylococcus aureus: Penicillin-resistant rate was 100%. No resistance to teicoplanin, linezolid, and vancomycin. The resistance rate of the MRSA isolates to clindamycin, erythromycin and tetracycline was higher than that of the MSSAs. Among the 65 MRSA isolates, the positive rate of PVL gene was 47.7% (31/65). Seventeen sequence types (STs) were identified among the 65 isolates, and ST59 was the most prevalent. SCCmec type III and IV were observed at 24.6 and 72.3%, respectively. Two isolates did not be typed. Twenty-one spa types were identified, spa t437 (34/65, 52.3%) was the most predominant type. MRSA major clone type of molecular typing was CC59-ST59-spa t437-IV (28/65, 43.1%). Overall, 188D feature vectors can be applied to successfully distinguish MRSA from MSSA. In Quanzhou, the detection rate of PVL virulence factor was high, suggesting a high pathogenic risk of MRSA infection. The cross-infection of CA-MRSA and HA-MRSA was presented, the molecular characteristics were increasingly blurred, HA-MRSA with typical CA-MRSA molecular characteristics has become an important cause of healthcare-related infections. CC59-ST59-spa t437-IV was the main clone type in Quanzhou, which was rare in other parts of mainland China.
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Affiliation(s)
- Zhimin Bai
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.,Department of Clinical Laboratory, Jinjiang Municipal Hospital, Jinjiang, China
| | - Min Chen
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.,Microbiological Laboratory Sanming Center for Disease Control and Prevention, Sanming, China
| | - Qiaofa Lin
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Ying Ye
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Hongmei Fan
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Kaizhen Wen
- Department of Clinical Laboratory, Jinjiang Municipal Hospital, Jinjiang, China
| | - Jianxing Zeng
- Department of Clinical Laboratory, Jinjiang Municipal Hospital, Jinjiang, China
| | - Donghong Huang
- Department of Clinical Laboratory, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wenfei Mo
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Ying Lei
- Department of Clinical Laboratory, Quanzhou Women's and Children's Hospital, Quanzhou, China
| | - Zhijun Liao
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
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Genovese C, La Fauci V, D'Amato S, Squeri A, Anzalone C, Costa GB, Fedele F, Squeri R. Molecular epidemiology of antimicrobial resistant microorganisms in the 21th century: a review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:256-273. [PMID: 32420962 PMCID: PMC7569612 DOI: 10.23750/abm.v91i2.9176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/10/2020] [Indexed: 12/26/2022]
Abstract
Healthcare-associated infections (HAIs) are the most frequent and severe complication acquired in healthcare settings with high impact in terms of morbidity, mortality and costs. Many bacteria could be implicated in these infections, but, expecially multidrug resistance bacteria could play an important role. Many microbial typing technologies have been developed until to the the bacterial whole-genome sequencing and the choice of a molecular typing method therefore will depend on the skill level and resources of the laboratory and the aim and scale of the investigation. In several studies the molecular investigation of pathogens involved in HAIs was performed with many microorganisms identified as causative agents such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Clostridium difficile, Acinetobacter spp., Enterobacter spp., Enterococcus spp., Staphylococcus aureus and several more minor species. Here, we will describe the most and least frequently reported clonal complex, sequence types and ribotypes with their worldwide geographic distribution for the most important species involved in HAIs.
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Affiliation(s)
- Cristina Genovese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Vincenza La Fauci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Smeralda D'Amato
- Postgraduate Medical School in Hygiene and Preventive Medicine, University of Messina, Italy.
| | - Andrea Squeri
- Department of Human Pathology of the adult and developmental age Gaetano Barresi, University of Messina, Messina, Italy.
| | - Carmelina Anzalone
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Gaetano Bruno Costa
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Francesco Fedele
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
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Chen YJ, Chen PA, Chen CJ, Huang YC. Molecular characteristics and clinical features of pediatric methicillin-susceptible Staphylococcus aureus infection in a medical center in northern Taiwan. BMC Infect Dis 2019; 19:402. [PMID: 31077140 PMCID: PMC6509804 DOI: 10.1186/s12879-019-4033-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 04/26/2019] [Indexed: 01/03/2023] Open
Abstract
Background There have been no reports regarding clinical features and molecular characteristics of childhood methicillin-susceptible Staphylococcus aureus (MSSA) infections in Taiwan. Methods We prospectively collected clinical S. aureus isolates from patients aged < 18 years in a university-affiliated hospital in 2015. Only the first isolate from each patient was included. Medical records were retrospectively reviewed. Patients were classified as community-associated (CA) or healthcare-associated (HA) by the epidemiologic criteria. All MSSA isolates were molecularly characterized. Results A total of 495 S. aureus isolates were identified, and 178 (36.0%) were MSSA. Among the 131 MSSA-infected patients enrolled, 94 (71.8%) were community-associated and 60 (45.8%) were inpatients. Patients with HA infections was significantly younger than those with CA infections (median, 15 vs. 67.5 months). The most common specimen of MSSA identified was pus or wound (73.3%). Compared to HA-MSSA, CA-MSSA isolates were significantly less frequently from sputum (6.4% vs. 27%, p = 0.001). Nineteen pulsotypes were identified. Four pulsotypes accounted for 60% of the isolates. Isolates of ST15/pulsotype F were more frequently seen in CA than in HA (p = 0.064) while isolates of ST188/pulsotype AX frequently seen in HA (p = 0.049). PVL genes were identified in 11 isolates (8.4%), nine of which were characterized as ST59/pulsotype D, same as the local endemic CA-MRSA clone. Conclusions MSSA accounted for around one-third of childhood S. aureus infections in northern Taiwan. SSTI was the most common manifestation. The molecular characteristics of these clinical MSSA isolates were relatively diverse and had certain significant differences between CA and HA isolates.
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Affiliation(s)
- Yu-Jen Chen
- School of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Po-An Chen
- School of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Chih-Jung Chen
- School of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan.,Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, No. 5, Fu-Shin Street, Kweishan, 333, Taoyuan, Taiwan
| | - Yhu-Chering Huang
- School of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan. .,Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, No. 5, Fu-Shin Street, Kweishan, 333, Taoyuan, Taiwan.
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Chen CH, Kuo KC, Hwang KP, Lin TY, Huang YC. Risk factors for and molecular characteristics of methicillin-resistant Staphylococcus aureus nasal colonization among healthy children in southern Taiwan, 2005-2010. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:929-936. [PMID: 30274893 DOI: 10.1016/j.jmii.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 09/03/2018] [Accepted: 09/11/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND/PURPOSE Nasal colonization of Staphylococcus aureus is a well-defined risk factor for subsequent infection. This study investigated the prevalence of methicillin-resistant S. aureus (MRSA) in southern Taiwan and aimed to identify the host factors for S. aureus colonization and the virulence factor of Panton-Valentine Leukocidin (PVL) genes. METHODS In a hospital-based study in Kaohsiung from Oct. 2005 to Dec. 2010, we performed nasal swab in the healthy children aged 2-60 months. We examined the relationship between the demographic characteristics and S. aureus nasal colonization. MRSA isolates were further analyzed for antimicrobial susceptibility and molecular characteristics. RESULTS Among 3020 healthy children, 840 (27.8%) children had S. aureus nasal colonization. Of 840 isolates, 246 (29.3%) isolates were MRSA. MRSA colonization was significantly associated with age 2-6 months, day care attendance, and influenza vaccination. Breastfeeding was a protective factor against MRSA colonization. Most MRSA isolates were susceptible to trimethoprim-sulfamethoxazole and doxycycline. Ninety-four percent of MRSA isolates carried either type IV staphylococcal cassette chromosome mec (SCCmec) or SCCmec VT and 87% belonged to the local community strains, namely clonal complex 59/SCCmec IV or VT. MRSA isolates with PVL-negative was associated with children with passive smoking. CONCLUSIONS Between 2005 and 2010, 27.8% and 8.14% of healthy children in southern Taiwan had nasal carriage of S. aureus and MRSA, respectively. Most MRSA isolates were local community strains. Several demographic factors associated with nasal MRSA colonization were identified.
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Affiliation(s)
- Chih-Ho Chen
- Division of Pediatric Infectious Diseases, Chang Gung Children's Hospital and Chang Gung Memorial Hospital at Kaohsiung, Taiwan
| | - Kuang-Che Kuo
- Division of Pediatric Infectious Diseases, Chang Gung Children's Hospital and Chang Gung Memorial Hospital at Kaohsiung, Taiwan
| | - Kao-Pin Hwang
- Division of Infectious Diseases, Children's Hospital, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Tzou-Yien Lin
- Division of Pediatric Infectious Diseases, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, Linko, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yhu-Chering Huang
- Division of Pediatric Infectious Diseases, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, Linko, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Wang HK, Huang CY, Huang YC. Clinical features and molecular characteristics of childhood community-associated methicillin-resistant Staphylococcus aureus infection in a medical center in northern Taiwan, 2012. BMC Infect Dis 2017; 17:470. [PMID: 28679429 PMCID: PMC5498897 DOI: 10.1186/s12879-017-2560-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 06/22/2017] [Indexed: 11/30/2022] Open
Abstract
Background Since first reported in 2002, the rate of methicillin-resistant Staphylococcus aureus (MRSA) among childhood community-associated (CA) S. aureus infection in Taiwan increased significantly up to 2005. There have been no reports on this issue since then. Methods We prospectively collected clinical S. aureus isolates from the patients <19 years of age in a university-affiliated hospital in 2012. Only first isolate from each patient was included. The medical records were retrospectively reviewed and the patients were classified as CA or healthcare-associated (HA) by the standard epidemiologic criteria. Isolates as CA-MRSA were further characterized by pulsed-field gel electrophoresis, staphylococcal cassette chromosome (SCCmec) typing, and multilocus sequence typing. Results A total of 409 S. aureus isolates were included, and 260 (63.6%) were MRSA. The proportion of MRSA among all S. aureus isolates in 2012 increased significantly (p < 0.001) compared to that in 2004–2005. Of the 181 CA-MRSA isolates, 86.2% were identified from pus or wound. Nine pulsotypes were identified with two major types (type D, 119 (65.7%); type C, 27 (14.9%). Most of the isolates carried either SCCmec IV (66 isolates, 36%) or VT (112 isolates, 62%). 128 isolates (71%) carried Panton-Valentine leukocidin (PVL) genes. Clonal complex (CC) 59 accounted for 146 isolates (80.7%) of two major pulsotypes, CC45 for 19 isolates, ST30 for 6 isolates and ST8 (USA 300) for 4 isolates. In addition to penicillin (100%), most isolates were resistant to erythromycin (81%) and clindamycin (79.3%). Conclusions Around two-thirds of childhood community-associated S. aureus infections in northern Taiwan were MRSA. Though CC59 is still the prevalent community clone, several new clones emerged in northern Taiwan.
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Affiliation(s)
- Hong-Kai Wang
- School of Medicine, Chang Gung University, Gueishan, Taoyuan, Taiwan
| | - Chun-Yen Huang
- School of Medicine, Chang Gung University, Gueishan, Taoyuan, Taiwan
| | - Yhu-Chering Huang
- School of Medicine, Chang Gung University, Gueishan, Taoyuan, Taiwan. .,Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, No. 5, Fu-Shin Street, Gueishan, 333, Taoyuan, Taiwan.
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Lin J, Lin D, Xu P, Zhang T, Ou Q, Bai C, Yao Z. Non-hospital environment contamination with Staphylococcus aureus and methicillin-resistant Staphylococcus aureus: proportion meta-analysis and features of antibiotic resistance and molecular genetics. ENVIRONMENTAL RESEARCH 2016; 150:528-540. [PMID: 27423707 DOI: 10.1016/j.envres.2016.06.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/28/2016] [Accepted: 06/25/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Staphylococcus aureus (S. aureus), including methicillin-resistant Staphylococcus aureus (MRSA), survives in dry conditions and can persist for long periods on surfaces touched by humans. Studies that estimate the proportions and characteristics of S. aureus and MRSA contamination in non-hospital environments are lacking. Therefore, we conducted a proportion meta-analysis and reviewed the features of antibiotic resistance and molecular genetics. METHODS Articles published between January 2005 and December 2015 that studied proportions of S. aureus and MRSA contamination in non-hospital environments were retrieved from the Medline database, Ovid database and Science Direct database. All statistics were analyzed by STATA 14.1. RESULTS Twenty-nine articles were included. The overall proportions of S. aureus and MRSA contamination were 41.1% (95%CI 29-54%) and 8.6% (95%CI 5-13%), respectively. The proportion of MRSA contamination increased over time. From the articles, the proportion of Panton-Valentine Leukociden (PVL) genes among MRSA isolates was 54.5%, and the proportion of the qac gene was 100.0%. Distribution of the multilocus sequence type (MLST) and pulsed-field gel electrophoresis (PFGE) of MRSA indicated that MRSA strains were from both hospitals and communities. CONCLUSION The overall proportions of S. aureus and MRSA contamination in non-hospital environments were high. The outcomes of antibiotic resistance and high proportions of PVL genes indicated that the antibiotic resistance of S. aureus and MRSA were notable. According to the different distributions of MLST and SCCmec of MRSA, we can infer that cross-circulation is within hospitals, communities, and livestock. The results also show that the risk from the MRSA strains was cross-transmitted among the population. High proportions of the qac gene of MRSA might indicate that current disinfection of MRSA has not been achieved, and it might be better to further identify the efficiency of the sterilization processes in a non-hospital environment so that relevant departments can take measures to improve disinfection of MRSA in non-hospital environments.
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Affiliation(s)
- Jialing Lin
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Dongxin Lin
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Ping Xu
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Ting Zhang
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Qianting Ou
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Chan Bai
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China
| | - Zhenjiang Yao
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou 510310, China.
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Huh K, Chung DR. Changing epidemiology of community-associated methicillin-resistant Staphylococcus aureus in the Asia-Pacific region. Expert Rev Anti Infect Ther 2016; 14:1007-1022. [PMID: 27645549 DOI: 10.1080/14787210.2016.1236684] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become an important threat to public health in the Asia-Pacific region, which is characterized by a large population and relatively insufficient resources. Better understanding on the current status of CA-MRSA in the region is of paramount importance. Areas covered: This article reviews the published literatures on the prevalence, molecular epidemiology, colonization, and hospital spread of CA-MRSA. Expert commentary: The burden of CA-MRSA has been increasing in the past two decades. The molecular epidemiology of CA-MRSA in the Asia-Pacific region shows a marked diversity in each country. Still, some strains - multilocus sequence type (MLST) ST59, ST30, ST72, ST8, and ST772 - are unique clones that have successfully established themselves as predominant, often spreading into nosocomial settings. More coordinated and comprehensive surveillance to understand the true epidemiology of CA-MRSA in the Asia-Pacific region is urgently needed.
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Affiliation(s)
- Kyungmin Huh
- a Division of Infectious Diseases, Department of Internal Medicine , Armed Forces Capital Hospital , Seongnam , Korea
| | - Doo Ryeon Chung
- b Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center , Sungkyunkwan University School of Medicine , Seoul , Korea
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