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Müller M, Wiencierz A, Gehringer C, Muigg V, Bassetti S, Siegemund M, Hinic V, Tschudin-Sutter S, Egli A. Factors associated with non-carbapenemase mediated carbapenem resistance of Gram-negative bacteria: a retrospective case-control study. Int Microbiol 2024; 27:597-606. [PMID: 37556067 PMCID: PMC10991015 DOI: 10.1007/s10123-023-00405-6] [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: 03/04/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 08/10/2023]
Abstract
Infections with carbapenemase-producing Gram-negative bacteria are related to increased morbidity and mortality, yet little is known regarding infections caused by non-beta-lactamase mediated carbapenem-resistant bacteria. Our objective was to identify risk factors for, and the clinical impact of infections caused by carbapenem-resistant carbapenemase-negative Enterobacterales and Pseudomonas aeruginosa. This retrospective matched case-control study was performed at the University Hospital of Basel, Switzerland, in 2016. We focused on other resistance mechanisms by excluding laboratory-confirmed carbapenemase-positive cases. Carbapenem resistance was set as the primary endpoint, and important risk factors were investigated by conditional logistic regression. The clinical impact of carbapenem resistance was estimated using regression models containing the resistance indicator as explanatory factor and adjusting for potential confounders. Seventy-five cases of infections with carbapenem-resistant, carbapenemase-negative bacteria were identified and matched with 75 controls with carbapenem-susceptible infections. The matched data set was well-balanced regarding age, gender, and comorbidity. Duration of prior carbapenem treatment (OR 1.15, [1.01, 1.31]) correlated with resistance to carbapenems. Our study showed that patients with carbapenem-resistant bacteria stayed 1.59 times (CI [0.81, 3.14]) longer in an ICU. The analyzed dataset did not provide evidence for strong clinical implications of resistance to carbapenems or increased mortality. The duration of prior carbapenem treatment seems to be a strong risk factor for the development of carbapenem resistance. The higher risk for a longer ICU stay could be a consequence of a carbapenem resistance. In contrast to carbapenemase-producers, the clinical impact of carbapenamase-negative, carbapenem-resistant strains may be limited. Trial registration: The study design was prospectively approved by the local Ethics Commission on 10.08.2017 (EKNZ BASEC 2017-00222).
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Affiliation(s)
- Marius Müller
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Christian Gehringer
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Veronika Muigg
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Medicine, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Vladimira Hinic
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland.
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland.
- Institute of Medical Microbiology, University of Zurich, Gloriastrasse 28/30, 8006, Zurich, Switzerland.
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Lemos GT, Terrabuio DRB, Nunes NN, Song ATW, Oshiro ICV, D'Albuquerque LAC, Levin AS, Abdala E, Freire MP. Pre-transplant multidrug-resistant infections in liver transplant recipients-epidemiology and impact on transplantation outcome. Clin Transplant 2024; 38:e15173. [PMID: 37877950 DOI: 10.1111/ctr.15173] [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] [Received: 05/30/2023] [Revised: 09/22/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Cirrhotic patients are highly exposed to healthcare services and antibiotics. Although pre-liver transplantation (LT) infections are directly related to the worsening of liver function, the impact of these infections on LT outcomes is still unclear. This study aimed to identify the effect of multidrug-resistant microorganism (MDRO) infections before LT on survival after LT. METHODS Retrospective study that included patients who underwent LT between 2010 and 2019. Variables analyzed were related to patients' comorbidities, underlying diseases, time on the waiting list, antibiotic use, LT surgery, and occurrences post-LT. Multivariate analyses were performed using logistic regression, and Cox regression for survival analysis. RESULTS A total of 865 patients were included; 351 infections were identified in 259 (30%) patients, of whom 75 (29%) had ≥1 pre-LT MDRO infection. The most common infection was spontaneous bacterial peritonitis (34%). The agent was identified in 249(71%), 53(15%) were polymicrobial. The most common microorganism was Klebsiella pneumoniae (18%); the most common MDRO was ESBL-producing Enterobacterales (16%), and carbapenem-resistant (CR) Enterobacterales (10%). Factors associated with MDRO infections before LT were previous use of therapeutic cephalosporin (p = .001) and fluoroquinolone (p = .001), SBP prophylaxis (p = .03), ACLF before LT (p = .03), and days of hospital stay pre-LT (p < .001); HCC diagnosis was protective (p = .01). Factors associated with 90-day mortality after LT were higher MELD on inclusion to the waiting list (p = .02), pre-LT MDRO infection (p = .04), dialysis after LT (p < .001), prolonged duration of LT surgery (p < .001), post-LT CR-Gram-negative bacteria infection (p < .001), and early retransplantation (p = .004). CONCLUSION MDRO infections before LT have an important impact on survival after LT.
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Affiliation(s)
- Gabriela T Lemos
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Debora R B Terrabuio
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Nathalia N Nunes
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Alice T W Song
- Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Isabel C V Oshiro
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Luiz Augusto C D'Albuquerque
- Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Edson Abdala
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Maristela P Freire
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
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3
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Ferstl PG, Bremer K, Filmann N, Kempf VAJ, Hogardt M, Ballo O, Finkelmeier F, Trebicka J, Zeuzem S, Bojunga J, Friedrich-Rust M, Walter D. Short Versus Long Antibiotic Therapy and Risk of Recurrence of Acute Cholangitis Due to Malignant Biliary Strictures. J Clin Med 2023; 12:6716. [PMID: 37959182 PMCID: PMC10648096 DOI: 10.3390/jcm12216716] [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: 09/04/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 11/15/2023] Open
Abstract
Malignancies can cause severe stenosis of the biliary tract and therefore predispose a patient to bacterial cholangitis. Upon endoscopic drainage, antibiotic therapy (AT) is performed according to individual clinical judgement, as the optimal duration of AT is unclear to date, especially in the case of multidrug-resistant organisms (MDROs). In a case-based retrospective study, patients with malignant biliary strictures and acute cholangitis were included upon endoscopic retrograde cholangiography (ERC). The outcome of cases treated with short AT (≤6 days) was compared to that of long AT (≥7 days). Recurrent cholangitis (RC) before scheduled stent exchange was the primary end point. In total, 124 patients were included, with 183 cases of proven cholangitis in total. The overall median duration of AT was 7 days (range 1-20), with 74 cases (40%) receiving short AT and 109 (60%) receiving long AT. Short AT was not an independent risk factor for RC (HR = 0.66, p > 0.2), while colonization with MDROs was associated with a higher risk of RC (HR = 2.21, p = 0.005). Placement of a metal stent was associated with minor risk of RC (HR = 0.4, p = 0.038). In conclusion, short AT is possible in selected patients with non-severe cholangitis and malignant biliary strictures. Scheduled screening for MDROs is recommended and placement of a metal stent should be performed if possible.
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Affiliation(s)
- Philip G. Ferstl
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Katharina Bremer
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Natalie Filmann
- Goethe University Frankfurt, Institute of Biostatistics and Mathematical Modeling, 60590 Frankfurt, Germany;
| | - Volkhard A. J. Kempf
- Goethe University Frankfurt, University Hospital, Institute for Medical Microbiology and Infection Control, University Center of Competence for Infection Control of the State of Hesse, 60590 Frankfurt, Germany; (V.A.J.K.); (M.H.)
| | - Michael Hogardt
- Goethe University Frankfurt, University Hospital, Institute for Medical Microbiology and Infection Control, University Center of Competence for Infection Control of the State of Hesse, 60590 Frankfurt, Germany; (V.A.J.K.); (M.H.)
| | - Olivier Ballo
- Goethe University Frankfurt, University Hospital, Medical Clinic 2, 60590 Frankfurt, Germany
| | - Fabian Finkelmeier
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Jonel Trebicka
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
- Department of Internal Medicine B, University of Münster, 48149 Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, 08021 Barcelona, Spain
| | - Stefan Zeuzem
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Jörg Bojunga
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Mireen Friedrich-Rust
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
| | - Dirk Walter
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, 60590 Frankfurt, Germany (F.F.); (J.T.); (S.Z.); (J.B.); (M.F.-R.); (D.W.)
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4
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Kinzler MN, Stehle A, Schulze F, Hogardt M, Wichelhaus TA, Kempf VAJ, Finkelmeier F, Trojan J, Zeuzem S, Schnitzbauer AA, Bechstein WO, Wild PJ, Walter D. Colonization with multidrug-resistant organisms is associated with impaired survival of patients with surgically resected cholangiocarcinoma. Liver Int 2023; 43:490-499. [PMID: 36424731 DOI: 10.1111/liv.15485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND & AIMS Colonization with multidrug-resistant organisms (MDRO) has been shown to impair survival in patients with various malignancies. Despite the increasing spread of MDRO, its impact on patients with cholangiocarcinoma (CCA) is unclear. Aim of this study was to analyse the impact of MDRO-colonization on overall prognosis in CCA patients. METHODS All patients with surgically resected CCA diagnosed between August 2005 and November 2021 at the University Hospital Frankfurt were screened for MDRO. CCA patients with a positive MDRO screening before or within the first 90 days after diagnosis of CCA were defined as colonized. Patients with a negative MDRO screening were defined as non-colonized. RESULTS Hundred and sixty nine patients were included. 32% (n = 54) were screened MDRO positive, while 68% (115) were non-colonized. Median overall survival (OS) for colonized patients was 17.1 months (95% CI = 9-25.2 months) compared to 50 months (95% CI = 37.1-62.8) for MDRO-negative patients (p ≤ .001). Non-cancer-related mortality (p ≤ .001) and infectious-related death (p ≤ .001) was significantly higher in the MDRO-colonized group. In multivariate analysis, MDRO colonization (HR = 2.1, 95% CI = 1.4-3.3, p = .001), ECOG 1 (HR = 2.5, 95% CI = 1.6-4, p ≤ .001) and N1 status (HR = 1.7, 95% CI = 1.1-2.6, p = .017) were independent risk factors for OS. CONCLUSION MDRO-colonization contributes to poor survival in patients with surgically resected CCA. MDRO surveillance is necessary to optimize clinical management of infections and to potentially reduce mortality in this critical population.
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Affiliation(s)
- Maximilian N Kinzler
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Angelika Stehle
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Falko Schulze
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University Frankfurt am Main and University Center of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Thomas A Wichelhaus
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University Frankfurt am Main and University Center of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University Frankfurt am Main and University Center of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Jörg Trojan
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas A Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Wolf O Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Peter J Wild
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Wildlab, University Hospital Frankfurt MVZ GmbH, Frankfurt am Main, Germany
| | - Dirk Walter
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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5
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Wang W, Wang R, Zhang Y, Zeng L, Kong H, Bai X, Zhang W, Liang T. Ceftazidime-Avibactam as Salvage Therapy in Pediatric Liver Transplantation Patients with Infections Caused by Carbapenem-Resistant Enterobacterales. Infect Drug Resist 2022; 15:3323-3332. [PMID: 35782529 PMCID: PMC9241992 DOI: 10.2147/idr.s369368] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/17/2022] [Indexed: 12/01/2022] Open
Abstract
Objective There are few therapeutic options for infections caused by carbapenem-resistant Enterobacterales (CRE) in children following liver transplantation. Ceftazidime-avibactam (CAZ-AVI), a recently licensed antibacterial in China, was utilized as a salvage therapy against CRE in our center, and its efficacy and safety were therefore assessed. Methods The retrospective, observational study was conducted at the First Affiliated Hospital of Zhejiang University. Pediatric liver transplantation patients (≤12 years) who received CAZ-AVI as a salvage therapy against CRE infections were included from January 2020 to December 2021. Clinical success and all-cause death during hospitalization were the primary outcomes. Recurrence of infection, drug-related adverse events, and changes in inflammatory biomarkers were collected. Results Six children were enrolled, with a median age of 10.1 (interquartile range (IQR) 5.5–13.8) months. Primary intraperitoneal infections occurred in all patients, with five patients developing bloodstream infections. KPC carbapenemases were detected in most isolates, and the susceptibility results showed general sensitivity to tigecycline, polymyxin B, and CAZ-AVI. Tigecycline-based therapy was taken as the initial treatment and withdrawn because of clinical failure (5 cases) or cholestasis (1 case). After CRE infection, the median time to convert to CAZ-AVI was 7.5 (IQR 7.0–8.8) days, and the median CAZ-AVI treatment length was 21.0 (IQR 20.3–28.5) days. Clinical success was achieved in all patients, with a zero percent all-cause death rate. No CRE infections recurred throughout hospitalization, and no resistance to CAZ-AVI was detected. Patients experienced vomiting (1/6), skin rash (1/6), and a transient increase in cystatin C (2/6), γ-glutamyltransferase (2/6), and alkaline phosphatase (3/6). Conclusion CAZ-AVI was shown to be a successful salvage treatment for CRE infection in pediatric liver transplant recipients, with minor and temporary drug-related side effects.
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Affiliation(s)
- Weili Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Rongrong Wang
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Yuntao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Lei Zeng
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Haisen Kong
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Wei Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Key Laboratory of Combined Multi-organ Transplantation of the Ministry of Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Correspondence: Tingbo Liang, Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China, Email
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6
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Schultze TG, Ferstl PG, Villinger D, Hogardt M, Bechstein WO, Göttig S, Wichelhaus TA, Zeuzem S, Trebicka J, Waidmann O, Welker MW, Kempf VAJ. Molecular Surveillance of Carbapenem-Resistant Gram-Negative Bacteria in Liver Transplant Candidates. Front Microbiol 2021; 12:791574. [PMID: 34880850 PMCID: PMC8645865 DOI: 10.3389/fmicb.2021.791574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Carbapenem-resistant Gram-negative bacteria (CRGN) cause life-threatening infections due to limited antimicrobial treatment options. The occurrence of CRGN is often linked to hospitalization and antimicrobial treatment but remains incompletely understood. CRGN are common in patients with severe illness (e.g., liver transplantation patients). Using whole-genome sequencing (WGS), we aimed to elucidate the evolution of CRGN in this vulnerable cohort and to reconstruct potential transmission routes. Methods: From 351 patients evaluated for liver transplantation, 18 CRGN isolates (from 17 patients) were analyzed. Using WGS and bioinformatic analysis, genotypes and phylogenetic relationships were explored. Potential epidemiological links were assessed by analysis of patient charts. Results: Carbapenem-resistant (CR) Klebsiella pneumoniae (n=9) and CR Pseudomonas aeruginosa (n=7) were the predominating pathogens. In silico analysis revealed that 14/18 CRGN did not harbor carbapenemase-coding genes, whereas in 4/18 CRGN, carbapenemases (VIM-1, VIM-2, OXA-232, and OXA-72) were detected. Among all isolates, there was no evidence of plasmid transfer-mediated carbapenem resistance. A close phylogenetic relatedness was found for three K. pneumoniae isolates. Although no epidemiological context was comprehensible for the CRGN isolates, evidence was found that the isolates resulted of a transmission of a carbapenem-susceptible ancestor before individual radiation into CRGN. Conclusion: The integrative epidemiological study reveals a high diversity of CRGN in liver cirrhosis patients. Mutation of carbapenem-susceptible ancestors appears to be the dominant way of CR acquisition rather than in-hospital transmission of CRGN or carbapenemase-encoding genetic elements. This study underlines the need to avoid transmission of carbapenem-susceptible ancestors in vulnerable patient cohorts.
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Affiliation(s)
- Tilman G Schultze
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
| | - Philip G Ferstl
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,Division of Gastroenterology and Hepatology, Department for Internal Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - David Villinger
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
| | - Wolf O Bechstein
- Department of General and Visceral Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Stephan Göttig
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
| | - Stefan Zeuzem
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,Division of Gastroenterology and Hepatology, Department for Internal Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Jonel Trebicka
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,Division of Gastroenterology and Hepatology, Department for Internal Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Oliver Waidmann
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,Division of Gastroenterology and Hepatology, Department for Internal Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Martin-Walter Welker
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,Division of Gastroenterology and Hepatology, Department for Internal Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany.,University Center of Competence for Infection Control of the State of Hesse, Frankfurt, Germany
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7
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Himmelsbach V, Knabe M, Ferstl PG, Peiffer KH, Stratmann JA, Wichelhaus TA, Hogardt M, Kempf VAJ, Zeuzem S, Waidmann O, Finkelmeier F, Ballo O. Colonization with multidrug-resistant organisms impairs survival in patients with hepatocellular carcinoma. J Cancer Res Clin Oncol 2021; 148:1465-1472. [PMID: 34283288 PMCID: PMC9114096 DOI: 10.1007/s00432-021-03741-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022]
Abstract
Introduction MDRO-colonization has been shown to impair survival in patients with hematological malignancies and solid tumors as well as in patients with liver disease. Despite the increasing spread of multidrug-resistant organisms (MDRO), its impact on patients with hepatocellular carcinoma (HCC) has not been studied. We conducted this retrospective study to analyze the impact of MDRO-colonization on overall prognosis in HCC patients. Materials and methods All patients with confirmed HCC diagnosed between January 2008 and December 2017 at the University Hospital Frankfurt were included in this study. HCC patients with a positive MDRO screening before or within the first 90 days after diagnosis of HCC were defined as colonized HCC patients, HCC patients with a negative MDRO screening were defined as noncolonized HCC patients. Results 59 (6%) colonized and 895 (94%) noncolonized HCC patients were included. Enterobacterales with extended-spectrum β-lactamase-like phenotype with or without resistance to fluoroquinolones (ESBL/ ± FQ) were the most frequently found MDRO with 59%, followed by vancomycin-resistant Enterococcus faecium with 37%. Colonized HCC patients had more severe cirrhosis and more advanced HCC stage compared to noncolonized HCC patients. Colonized HCC patients showed an impaired survival with a median OS of 189 days (6.3 months) compared to a median OS of 1001 days (33.4 months) in noncolonized HCC patients. MDRO-colonization was identified as an independent risk factor associated with survival in multivariate analysis. Conclusion MDRO-colonization is an independent risk factor for survival in patients with HCC highlighting the importance of regular MDRO screening, isolation measures as well as interdisciplinary antibiotic steward-ship programs to guide responsible use of antibiotic agents.
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Affiliation(s)
- Vera Himmelsbach
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Mate Knabe
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Phillip G Ferstl
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Kai-Henrik Peiffer
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Jan A Stratmann
- University Cancer Center, Goethe University Hospital, Frankfurt/Main, Germany
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt/Main, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt/Main, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt/Main, Germany
| | - Stefan Zeuzem
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Oliver Waidmann
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
- University Cancer Center, Goethe University Hospital, Frankfurt/Main, Germany
| | - Fabian Finkelmeier
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
- University Cancer Center, Goethe University Hospital, Frankfurt/Main, Germany
| | - Olivier Ballo
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany.
- University Cancer Center, Goethe University Hospital, Frankfurt/Main, Germany.
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany.
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8
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Abstract
Liver cirrhosis is a major healthcare problem. Acute decompensation, and in particular its interplay with dysfunction of other organs, is responsible for the majority of deaths in patients with cirrhosis. Acute decompensation has different courses, from stable decompensated cirrhosis over unstable decompensated cirrhosis to pre-acute-on-chronic liver failure and finally acute-on-chronic liver failure, a syndrome with high short-term mortality. This review focuses on the recent developments in the field of acute decompensation and acute-on-chronic liver failure.
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Affiliation(s)
- Philip Ferstl
- Department for Internal Medicine I, University Hospital, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Jonel Trebicka
- Department for Internal Medicine I, University Hospital, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany; European Foundation for the Study of Chronic Liver Failure, Travesera de Gracia 11, 08021 Barcelona, Spain.
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9
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Ferstl PG, Filmann N, Heilgenthal EM, Schnitzbauer AA, Bechstein WO, Kempf VAJ, Villinger D, Schultze TG, Hogardt M, Stephan C, Mutlak H, Weiler N, Mücke MM, Trebicka J, Zeuzem S, Waidmann O, Welker MW. Colonization with multidrug-resistant organisms is associated with in increased mortality in liver transplant candidates. PLoS One 2021; 16:e0245091. [PMID: 33481811 PMCID: PMC7822319 DOI: 10.1371/journal.pone.0245091] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023] Open
Abstract
Objectives Rising prevalence of multidrug-resistant organisms (MDRO) is a major health problem in patients with liver cirrhosis. The impact of MDRO colonization in liver transplantation (LT) candidates and recipients on mortality has not been determined in detail. Methods Patients consecutively evaluated and listed for LT in a tertiary German liver transplant center from 2008 to 2018 underwent screening for MDRO colonization including methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant gram-negative bacteria (MDRGN), and vancomycin-resistant enterococci (VRE). MDRO colonization and infection status were obtained at LT evaluation, planned and unplanned hospitalization, three months upon graft allocation, or at last follow-up on the waiting list. Results In total, 351 patients were listed for LT, of whom 164 (47%) underwent LT after a median of 249 (range 0–1662) days. Incidence of MDRO colonization increased during waiting time for LT, and MRDO colonization was associated with increased mortality on the waiting list (HR = 2.57, p<0.0001. One patients was colonized with a carbapenem-resistant strain at listing, 9 patients acquired carbapenem-resistant gram-negative bacteria (CRGN) on the waiting list, and 4 more after LT. In total, 10 of these 14 patients died. Conclusions Colonization with MDRO is associated with increased mortality on the waiting list, but not in short-term follow-up after LT. Moreover, colonization with CRGN seems associated with high mortality in liver transplant candidates and recipients.
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Affiliation(s)
- Philip G. Ferstl
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
- * E-mail:
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt am Main, Frankfurt, Germany
| | - Eva-Maria Heilgenthal
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Andreas A. Schnitzbauer
- Department of General and Visceral Surgery, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Wolf O. Bechstein
- Department of General and Visceral Surgery, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Volkhard A. J. Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - David Villinger
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Tilman G. Schultze
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Christoph Stephan
- Department for Internal Medicine II / Infectious Diseases, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Haitham Mutlak
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Nina Weiler
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Marcus M. Mücke
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Jonel Trebicka
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Oliver Waidmann
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Martin-Walter Welker
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
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10
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Xin R, Zhang K, Wu N, Zhang Y, Niu Z. The pollution level of the bla OXA-58 carbapenemase gene in coastal water and its host bacteria characteristics. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2019; 244:66-71. [PMID: 30321713 DOI: 10.1016/j.envpol.2018.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/30/2018] [Accepted: 10/03/2018] [Indexed: 06/08/2023]
Abstract
This paper investigated 10 carbapenemase genes and selected the hosts of these genes in the estuary of Bohai Bay. The results showed that the OXA-58 producer accounted for a large percentage of carbapenem resistant bacteria in the sampling points, whereas the VIM, KPC, NDM, IMP, GES, OXA-23, OXA-24, OXA-48 and OXA-51 producers were not detected in the study. In addition, 9 bacterial genera with 100% identical blaOXA-58 sequences, including Pseudomonas, Rheinheimera, Stenotrophomonas, Shewanella, Raoultella, Vibrio, Pseudoalteromonas, Algoriphagus, Bowmanella and Thalassospira, were isolated from seawater. It is suggested that the host of blaOXA-58 gene were varied and many kinds of them could survive in the seawater. Moreover, we preformed the quantitative RT-PCR and the result shown the abundance of blaOXA-58 fluctuated between 2.8×10-6 copies/16S and 2.46×10-4 copies/16S, which was of the same order of magnitude as some common antibiotic resistance genes in environment. Furthermore, the variation trend of blaOXA-58 gene suggested that pollution discharge and horizontal gene transfer could contribute to the increase of the gene in coastal area.
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Affiliation(s)
- Rui Xin
- School of Marine Science and Technology, Tianjin University, Tianjin, 300072, China
| | - Kai Zhang
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
| | - Nan Wu
- School of Marine Science and Technology, Tianjin University, Tianjin, 300072, China
| | - Ying Zhang
- MOE Key Laboratory of Pollution Processes and Environmental Criteria, College of Environmental Science and Engineering, Nankai University, Tianjin, 300350, China
| | - Zhiguang Niu
- School of Marine Science and Technology, Tianjin University, Tianjin, 300072, China; School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China.
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11
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Ferstl PG, Müller M, Filmann N, Hogardt M, Kempf VA, Wichelhaus TA, Lange CM, Vermehren J, Zeuzem S, Reinheimer C, Waidmann O. Noninvasive screening identifies patients at risk for spontaneous bacterial peritonitis caused by multidrug-resistant organisms. Infect Drug Resist 2018; 11:2047-2061. [PMID: 30464547 PMCID: PMC6223386 DOI: 10.2147/idr.s172587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and aims Spontaneous bacterial peritonitis (SBP) is a severe complication of decompensated cirrhosis. The prevalence of multidrug-resistant organisms (MDROs) in patients with cirrhosis is increasing. Identification of patients at risk for SBP due to MDROs (ie, SBP with the evidence of MDROs or Stenotrophomonas maltophilia in ascitic culture, MDRO-SBP) is crucial to the early adaptation of antibiotic treatment in such patients. We therefore investigated whether MDROs found in ascitic cultures can also be found in specimens determined by noninvasive screening procedures. Patients and methods This retrospective study was conducted at the liver center of the University Hospital Frankfurt, Germany. Between 2011 and 2016, patients with cirrhosis were included upon diagnosis of SBP and sample collection of aerobic/anaerobic ascitic cultures. Furthermore, the performance of at least one complete MDRO screening was mandatory for study inclusion. Results Of 133 patients diagnosed with SBP, 75 (56.4%) had culture-positive SBP and 22 (16.5%) had MDRO-SBP. Multidrug-resistant Escherichia coli (10/22; 45.5%) and vancomycin-resistant enterococci (7/22; 36.4%) resembled the major causatives of MDRO-SBP. Rectal swabs identified MDROs in 17 of 22 patients (77.3%) who developed MDRO-SBP with a time-dependent sensitivity of 77% and 87% after 30 and 90 days upon testing, while negative predictive value was 83% and 76%, respectively. The majority of patients were included from intensive care unit or intermediate care unit. Conclusion MDRO screening may serve as a noninvasive diagnostic tool to identify patients at risk for MDRO-SBP. Patients with decompensated cirrhosis should be screened for MDROs from the first day of inpatient treatment onward.
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Affiliation(s)
- Philip G Ferstl
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Mona Müller
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Hogardt
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Volkhard Aj Kempf
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Thomas A Wichelhaus
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Christian M Lange
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Johannes Vermehren
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Stefan Zeuzem
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Claudia Reinheimer
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Oliver Waidmann
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
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12
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Lutz P, Nattermann J. Misery acquaints a man with dangerous bedfellows: But how to get rid of them? Liver Int 2017; 37:1446-1448. [PMID: 28940955 DOI: 10.1111/liv.13472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, Bonn, Germany
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