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Ogihara S, Yamaguchi T, Sato T, Aoki K, Komori K, Sasaki M, Murakami H, Ishii Y, Tateda K. Assessing the discriminability of PCR-based open reading frame typing versus single-nucleotide polymorphism analysis via draft whole-genome sequencing of methicillin-resistant Staphylococcus aureus in nosocomial transmission analysis. J Infect Chemother 2024; 30:951-954. [PMID: 38437985 DOI: 10.1016/j.jiac.2024.02.021] [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: 01/05/2024] [Revised: 02/04/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024]
Abstract
Phylogenetic analysis based on single-nucleotide polymorphism (SNP)-based through whole-genome sequencing is recognized as the standard method for probing nosocomial transmission. However, the application of WGS is constrained by the high cost of equipment and the need for diverse analysis tools, which limits its widespread use in clinical laboratory settings. In Japan, the prevalent use of PCR-based open reading frame typing (POT) for tracing methicillin-resistant Staphylococcus aureus (MRSA) transmission routes is attributed to its simplicity and ease of use. Although POT's discriminatory power is considered insufficient for nosocomial transmission analysis, conclusive data supporting this notion is lacking. This study assessed the discriminatory capabilities of SNP analysis and POT across 64 clinical MRSA strains. All 21 MRSA strains of ST5/SCCmec IIa, having more than 16 SNPs, demonstrated distinct clones. Conversely, two strains shared the same POT number and were identified as group A. Among the 12 MRSA strains of ST8/SCCmec IVl with over nine SNPs, five fell into POT group B, and five into POT group C. All four MRSA strains of ST8/SCCmec IVa were classified into POT group D, although they included strains with more than 30 SNPs. Among the 27 MRSA strains of ST1/SCCmec IVa, 14 were classified into POT group E. However, except for two clusters (each comprising two or three strains), all had SNP counts >10 (Fig. 1-D). SNP analysis of MRSA in CC1/SCCmec IV showed that several strains had the same number of SNPs in POT number (106-183-37), even among bacteria with >100 SNPs, indicating POT's limited use in detailed nosocomial transmission analysis.
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Affiliation(s)
- Shinji Ogihara
- Department of Clinical Laboratory, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan; Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Tetsuo Yamaguchi
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.
| | - Takahiro Sato
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan; Department of General Medicine and Emergency Care, Toho University Omori 12 Medical Center, Tokyo, Japan
| | - Kotaro Aoki
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kohji Komori
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Masakazu Sasaki
- Department of Clinical Laboratory, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Hinako Murakami
- Department of Clinical Laboratory, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Yoshikazu Ishii
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kazuhiro Tateda
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, 5-21-16, Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
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Mitsumoto-Kaseida F, Murata M, Ota K, Kaku N, Kosai K, Hasegawa H, Hayashi J, Yanagihara K. Comparison of the effectiveness of core genome multilocus sequence typing and polymerase chain reaction-based open reading frame typing in tracing nosocomial methicillin-resistant Staphylococcus aureus transmission. J Infect Chemother 2024:S1341-321X(24)00179-X. [PMID: 38969102 DOI: 10.1016/j.jiac.2024.07.001] [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: 03/18/2024] [Revised: 05/27/2024] [Accepted: 07/02/2024] [Indexed: 07/07/2024]
Abstract
INTRODUCTION A clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II/ST5 methicillin-resistant Staphylococcus aureus (MRSA) to SCCmec type IV/clonal complex (CC)1 MRSA has occurred rapidly in Japan. Our previous research in a geriatric hospital found SCCmec type IV/CC1 MRSA prevalence in long-term care wards. Due to intensive personal care requirements, frequent contact with healthcare providers can potentially cause unintentional nosocomial MRSA transmission. We performed polymerase chain reaction-based open reading frame typing (POT) and core genome multilocus sequence typing (cgMLST) to investigate the occurrence of nosocomial transmission and to compare the results of these methods. METHODS POT and whole genome sequencing were performed in 83 MRSA isolates. Commercial automated software (Ridom SeqSphere+) was used to perform cgMLST. MRSA isolates with 0-8 allelic differences were considered related, and medical records were consulted in these cases. RESULTS SCCmec type IV/CC1 MRSA was the most frequently detected clone (n = 56, 67.5 %), which was divided into 14 POT types, followed by SCCmec type I/ST8 (n = 9) and SCCmec type IV/ST8 (n = 8). Identical POT types were found across 7 of 11 wards. However, cgMLST analysis identified only three cases (six strains) of high genetic similarity, indicating nosocomial transmission; only one involved SCCmec type IV/CC1 (two strains). The mean allelic difference in the core genomes between strains with identical POT types in the same ward was 55.3 ± 22.0. CONCLUSIONS The cgMLST method proved more effective for identifying nosocomial transmissions compared to POT, highlighting its utility in tracking MRSA spread in healthcare settings.
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Affiliation(s)
- Fujiko Mitsumoto-Kaseida
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan; Kyushu General Medicine Center, Haradoi Hospital, 6-40-8 Aoba, Higashi-ku, Fukuoka, 813-8588, Japan.
| | - Mika Murata
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Kenji Ota
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Norihito Kaku
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Kosuke Kosai
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Hiroo Hasegawa
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Jun Hayashi
- Kyushu General Medicine Center, Haradoi Hospital, 6-40-8 Aoba, Higashi-ku, Fukuoka, 813-8588, Japan.
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
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Takeuchi N, Ishiwada N. Importance of Toxin Genes and Polymerase Chain Reaction-Based Open Reading Frame Type Analyses for Severe Staphylococcus aureus Infection in Children. Jpn J Infect Dis 2023; 76:376-380. [PMID: 37648487 DOI: 10.7883/yoken.jjid.2023.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
This study analyzed 26 Staphylococcus aureus strains, including 16 methicillin-resistant S. aureus (MRSA) and 10 methicillin-susceptible S. aureus (MSSA), collected from eight medical institutions in the Chiba Prefecture that requested a toxin gene analysis between 2015 and 2021. A total of 14 Panton-Valentine leukocidin (PVL) positive strains were identified, including MSSA. PVL-positive strains were classified into seven types according to polymerase chain reaction-based open reading frame typing (POT); of these types, three POT MRSA strains have not been previously reported, and one has been previously reported as PVL-negative. Some strains tested positive for both PVL and toxic shock syndrome toxin 1. One POT type was identified in both PVL-positive and PVL-negative strains. To the best of our knowledge, this is the first report on the regional spread of highly pathogenic S. aureus strains based on the POT method in children from multiple medical institutions. This method is useful for estimating the spread of toxin gene-carrying strains in the community owing to its association with toxin genes. As the number of PVL-positive strains in Japan increases, it is important to analyze the isolates of severe S. aureus infections in children by combining toxin gene analyses with the POT method.
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Affiliation(s)
- Noriko Takeuchi
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University, Japan
| | - Naruhiko Ishiwada
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University, Japan
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Mitsumoto-Kaseida F, Morinaga Y, Sasaki D, Ota K, Kaku N, Sakamoto K, Kosai K, Hasegawa H, Hayashi J, Yanagihara K. The clinical characteristics and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) among very elderly people in Japan. Geriatr Gerontol Int 2023; 23:744-749. [PMID: 37694453 DOI: 10.1111/ggi.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/02/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
AIM Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial infection-causing pathogen. The clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II MRSA to SCCmec type IV MRSA has occurred rapidly in acute-care hospitals. However, the epidemiology and clinical impacts of MRSA in geriatric hospitals are poorly documented. We performed a molecular epidemiological analysis of the clinical isolates and retrospectively investigated the clinical characteristics of SCCmec type IV MRSA in elderly individuals. METHODS MRSA isolates were grouped according to the SCCmec type and virulence genes (tst, sea, seb, sec, and lukS/F-PV), and multi-locus sequence typing (MLST) was performed. RESULTS Of the 145 MRSA isolates obtained from patients with a median age of 85 years, 100 (69.0%) were obtained from sputum samples, 22 (15.2%) from skin and soft tissues, and seven (4.8%) from blood samples. The most prevalent clone was SCCmec type IV/clonal complex (CC)1/sea+ (59.3%), followed by SCCmec type I/sequence type (ST) 8 (17.3%). Of the 17 (11.7%) strains to which an anti-MRSA drug was administered by a physician, only three were SCCmec type IV/CC1/sea+ (17.6%) and five were SCCmec type I/ST8 (29.4%). SCCmec type IV/CC1/sea+ MRSA was more frequently isolated in long-term care wards than were SCCmec type I/ST8 strains (odds ratio: 2.85, 95% confidence interval: 1.08-7.54) and was less frequently treated as the cause of MRSA infections (odds ratio: 0.15, 95% confidence interval: 0.03-0.73). CONCLUSIONS SCCmec type IV/CC1/sea+ MRSA was the predominant clone and could be easily transmissible and be capable of colonization. Geriatr Gerontol Int 2023; 23: 744-749.
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Affiliation(s)
- Fujiko Mitsumoto-Kaseida
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Kyushu General Medicine Center, Haradoi Hospital, Fukuoka, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Daisuke Sasaki
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kenji Ota
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norihito Kaku
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kei Sakamoto
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kosuke Kosai
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroo Hasegawa
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Jun Hayashi
- Kyushu General Medicine Center, Haradoi Hospital, Fukuoka, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Toyama Y, Hisata K, Kasai Y, Nakano S, Komatsu M, Shimizu T. Molecular epidemiology of methicillin-sensitive Staphylococcus aureus in the neonatal intensive care unit. J Hosp Infect 2022; 129:75-81. [PMID: 35987317 DOI: 10.1016/j.jhin.2022.07.026] [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: 04/12/2022] [Revised: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Staphylococcus aureus-both meticillin-resistant S. aureus (MRSA) and meticillin-sensitive S. aureus (MSSA)-is a major cause of neonatal infections. Infection control measures have not lowered the incidence of MSSA infections to the same degree as that of MRSA infections. AIM To investigate the transmission pathway of MSSA in neonatal intensive care unit (NICU) using genetic analysis. METHODS We swab-tested neonatal patients, their parents, and healthcare workers (HCW) in the NICU at our hospital at the time of hospitalisation and then every month thereafter from 1st October 2018 to 31st March 2019. We performed whole-genome sequencing (WGS) to test for MSSA strains. Multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis were used to identify strains and understand their relatedness. FINDINGS There were 16 MSSA-positive patients. Four MSSA-positive patients shared strains from the same phylogenetic groups as those of HCW. One presented the same strain as the parent. MSSA-positive twin neonates shared the same strain. Ten had sporadic strains; 32 of the ninety-seven tested healthcare workers were MSSA positive. CONCLUSION The findings of this study suggest that the route of transmission of MSSA in NICU may be through MSSA in the hospital environment in addition to horizontal transmission via healthcare workers. Along with hand hygiene with alcohol, thorough environmental maintenance and parental education are important for infection control in NICUs targeting MSSA.
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Affiliation(s)
- Yudai Toyama
- Department of Pediatrics and Adolescent Medicine, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ken Hisata
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan.
| | - Yuriha Kasai
- Department of Pediatrics and Adolescent Medicine, Graduate School of Medicine, Juntendo University, Tokyo, Japan; Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Saki Nakano
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; Department of Pediatrics, Tokyo Rinkai Hospital, Tokyo, Japan
| | - Mitsutaka Komatsu
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Sundermann AJ, Chen J, Miller JK, Martin EM, Snyder GM, Van Tyne D, Marsh JW, Dubrawski A, Harrison LH. Whole-genome sequencing surveillance and machine learning for healthcare outbreak detection and investigation: A systematic review and summary. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e91. [PMID: 36483409 PMCID: PMC9726481 DOI: 10.1017/ash.2021.241] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/04/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND Whole-genome sequencing (WGS) has traditionally been used in infection prevention to confirm or refute the presence of an outbreak after it has occurred. Due to decreasing costs of WGS, an increasing number of institutions have been utilizing WGS-based surveillance. Additionally, machine learning or statistical modeling to supplement infection prevention practice have also been used. We systematically reviewed the use of WGS surveillance and machine learning to detect and investigate outbreaks in healthcare settings. METHODS We performed a PubMed search using separate terms for WGS surveillance and/or machine-learning technologies for infection prevention through March 15, 2021. RESULTS Of 767 studies returned using the WGS search terms, 42 articles were included for review. Only 2 studies (4.8%) were performed in real time, and 39 (92.9%) studied only 1 pathogen. Nearly all studies (n = 41, 97.6%) found genetic relatedness between some isolates collected. Across all studies, 525 outbreaks were detected among 2,837 related isolates (average, 5.4 isolates per outbreak). Also, 35 studies (83.3%) only utilized geotemporal clustering to identify outbreak transmission routes. Of 21 studies identified using the machine-learning search terms, 4 were included for review. In each study, machine learning aided outbreak investigations by complementing methods to gather epidemiologic data and automating identification of transmission pathways. CONCLUSIONS WGS surveillance is an emerging method that can enhance outbreak detection. Machine learning has the potential to identify novel routes of pathogen transmission. Broader incorporation of WGS surveillance into infection prevention practice has the potential to transform the detection and control of healthcare outbreaks.
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Affiliation(s)
- Alexander J. Sundermann
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jieshi Chen
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - James K. Miller
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Elise M. Martin
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Infection Prevention and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Infection Prevention and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, Pennsylvania
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jane W. Marsh
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Artur Dubrawski
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Lee H. Harrison
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Ogura K, Kaji D, Sasaki M, Otsuka Y, Takemoto N, Miyoshi-Akiyama T, Kikuchi K. Predominance of ST8 and CC1/spa-t1784 methicillin-resistant Staphylococcus aureus isolates in Japan and their genomic characteristics. J Glob Antimicrob Resist 2022; 28:195-202. [DOI: 10.1016/j.jgar.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/06/2022] [Accepted: 01/17/2022] [Indexed: 11/16/2022] Open
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Methicillin-Resistant Staphylococcus aureus (MRSA) Clonal Replacement in a Malaysian Teaching Hospital: Findings from an Eight-Year Interval Molecular Surveillance. Antibiotics (Basel) 2021; 10:antibiotics10030320. [PMID: 33808728 PMCID: PMC8003425 DOI: 10.3390/antibiotics10030320] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
Periodical surveillance on nosocomial pathogens is important for antimicrobial stewardship and infection control. The first methicillin-resistant Staphylococcus aureus (MRSA) molecular surveillance in Hospital Canselor Tuanku Muhriz (HCTM), a Malaysian teaching hospital, was performed in 2009. The dominant clone was identified as an MRSA carrying SCCmec type III-SCCmercury with ccrC and sea+cna toxin genes. In this study, we report the findings of the second HCTM MRSA surveillance carried out in 2017, after an interval of 8 years. Antibiotic susceptibility testing, SCCmec, toxin gene, and spa typing were performed for 222 MRSA strains isolated in 2017. Most strains were resistant to ciprofloxacin, erythromycin, clindamycin, cefoxitin, and penicillin (n = 126, 56.8%), belong to SCCmec type IV (n = 205, 92.3%), spa type t032 (n = 160, 72.1%) and harboured seg+sei toxin genes (n = 172, 77.5%). There was significant association between resistance of the aforementioned antibiotics with SCCmec type IV (p < 0.05), t032 (p < 0.001), and seg+sei carriage (p < 0.05). Results from this second MRSA surveillance revealed the occurrence of clonal replacement in HCTM during an interval of not more than 8 years. Investigation of the corresponding phenotype changes in this new dominant MRSA clone is currently on-going.
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Regional outbreak of methicillin-resistant Staphylococcus aureus ST2725-t1784 in rural Japan. Infect Control Hosp Epidemiol 2020; 42:1294-1296. [PMID: 33161919 DOI: 10.1017/ice.2020.1265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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