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Guinea J, Alcoceba E, Padilla E, Ramírez A, De Carolis E, Sanguinetti M, Muñoz-Algarra M, Durán-Valle T, Quiles-Melero I, Merino P, González-Romo F, Sánchez-García A, Gómez-García-de-la-Pedrosa E, Pérez-Ayala A, Mantecón-Vallejo MÁ, Pemán J, Cuétara MS, Zurita ND, García-Esteban C, Martínez-Jiménez MDC, Sánchez Castellano MÁ, Reigadas E, Muñoz P, Escribano P. Fluconazole-resistant Candida parapsilosis: fast detection of the Y132F ERG11p substitution, and a proposed microsatellite genotyping scheme. Clin Microbiol Infect 2024:S1198-743X(24)00313-6. [PMID: 39002661 DOI: 10.1016/j.cmi.2024.07.002] [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: 02/12/2024] [Revised: 05/06/2024] [Accepted: 07/02/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES We propose fast and accurate molecular detection of the Y132F ERG11p substitution directly on pure-cultured C. parapsilosis isolates. We also assessed a discriminative genotyping scheme to track circulating genotypes. METHODS A total of 223 C. parapsilosis isolates (one patient each) from 20 hospitals, located in Spain and Italy were selected. Isolates were fluconazole-resistant (n=94; harbouring the Y132F ERG11p substitution [n=85], the G458S substitution [n=6], the R398I substitution [n=2], or the wild-type ERG11 gene sequence) or fluconazole-susceptible (n=129). Two targeted-A395T-mutation PCR formats (conventional and real-time) were engineered and optimized on fluconazole-susceptible and fluconazole-resistant pure-cultured isolates, thus skipping DNA extraction. Two genotyping schemes were compared: Scheme 1 (CP1, CP4a, CP6, and B markers), and Scheme 2 (6A, 6B, 6C, CP1, CP4a, and CP6 markers). RESULTS The screening performed using both PCR formats showed 100% specificity (fluconazole-susceptible isolates; n=129/129) and sensitivity (Y132F isolates; n=85/85) values, however, results were available in 3 and 1.5 hours with the conventional and real-time PCR formats, respectively. Overall, Scheme 1 showed higher genetic diversity than Scheme 2, as shown by the number of alleles detected (n=98; mean 23, range 13-38), the significantly higher observed and expected heterozygosity, and the probability of identity index (2.5x10-6). Scheme 2 markers did not provide further genotypic discrimination of Y132F fluconazole-resistant genotypes. CONCLUSION Both proposed PCR formats allow to speed up the accurate detection of substitution Y132F ERG11p in C. parapsilosis isolates with 100% specificity and sensitivity. In addition, we recommend CP1, CP4a, CP6, and B microsatellite markers for genotyping fluconazole-resistant isolates.
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Affiliation(s)
- Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid (Spain); Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid (Spain); CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Faculty of Health Sciences - HM Hospitals, Universidad Camilo José Cela, Madrid, Spain.
| | - Eva Alcoceba
- Clinical Microbiology Department, Hospital Universitari Son Espases, Mallorca, Spain
| | | | - Aída Ramírez
- Clinical Microbiology department. Hospital del Mar, Barcelona Spain
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - María Muñoz-Algarra
- Clinical Microbiology Department, Hospital Universitario Puerta de Hierro Majadahonda, 28220 Madrid, Spain
| | - Teresa Durán-Valle
- Clinical Microbiology Department, Hospital Universitario de Móstoles, Móstoles, 28935 Madrid, Spain
| | | | - Paloma Merino
- Clinical Microbiology Department, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos IdISSC, 28040 Madrid, Spain
| | - Fernando González-Romo
- Clinical Microbiology Department, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos IdISSC, 28040 Madrid, Spain
| | - Aída Sánchez-García
- Laboratorio Central de la CAM-URSalud-Hospital Infanta Sofía, San Sebastián de los Reyes, 28703 Madrid, Spain
| | - Elia Gómez-García-de-la-Pedrosa
- Clinical Microbiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Pérez-Ayala
- Clinical Microbiology Department, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital 12 de Octubre, 28041 Madrid, Spain
| | | | - Javier Pemán
- Hospital Universitario y Politécnico La Fé, Valencia, Spain
| | - María Soledad Cuétara
- Clinical Microbiology Department, Hospital Universitario Severo Ochoa, Leganés, Spain
| | | | | | | | | | - Elena Reigadas
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid (Spain); Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid (Spain); CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid (Spain); Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid (Spain); CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid (Spain); Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid (Spain); Faculty of Health Sciences - HM Hospitals, Universidad Camilo José Cela, Madrid, Spain.
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Ning YT, Sun TS, Dai RC, Luo ZY, Yu SY, Zhang G, Mei YN, Lin YL, Hasi CL, Chen SCA, Kong FR, Xiao M, Xu YC, Zhang L. Emergence of multiple fluconazole-resistant Candida parapsilosis sensu stricto clones with persistence and transmission in China. J Antimicrob Chemother 2024; 79:128-133. [PMID: 37991189 PMCID: PMC10761258 DOI: 10.1093/jac/dkad356] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES We explored the epidemiological and molecular characteristics of Candida parapsilosis sensu stricto isolates in China, and their mechanisms of azole resistance. METHODS Azole susceptibilities of 2318 non-duplicate isolates were determined using CLSI broth microdilution. Isolates were genotyped by a microsatellite typing method. Molecular resistance mechanisms were also studied and functionally validated by CRISPR/Cas9-based genetic alterations. RESULTS Fluconazole resistance occurred in 2.4% (n = 56) of isolates, and these isolates showed a higher frequency of distribution in ICU inpatients compared with susceptible isolates (48.2%, n = 27/56 versus 27.8%, 613/2208; P = 0.019). Microsatellite-genotyping analysis yielded 29 genotypes among 56 fluconazole-resistant isolates, of which 10 genotypes, including 37 isolates, belonged to clusters, persisting and transmitting in Chinese hospitals for 1-29 months. Clusters harbouring Erg11Y132F (5/10; 50%) were predominant in China. Among these, the second most dominant cluster MT07, including seven isolates, characteristically harbouring Erg11Y132F and Mrr1Q625K, lent its carriage to being one of the strongest associations with cross-resistance and high MICs of fluconazole (>256 mg/L) and voriconazole (2-8 mg/L), causing transmission across two hospitals. Among mutations tested, Mrr1Q625K led to the highest-level increase of fluconazole MIC (32-fold), while mutations located within or near the predicted transcription factor domain of Tac1 (D440Y, T492M and L518F) conferred cross-resistance to azoles. CONCLUSIONS This study is the first Chinese report of persistence and transmissions of multiple fluconazole-resistant C. parapsilosis sensu stricto clones harbouring Erg11Y132F, and the first demonstration of the mutations Erg11G307A, Mrr1Q625K, Tac1L263S, Tac1D440Y and Tac1T492M as conferring resistance to azoles.
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Affiliation(s)
- Ya-Ting Ning
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Tian-Shu Sun
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
- Clinical Biobank, Medical Research Centre, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Rong-Chen Dai
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zheng-Yu Luo
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Shu-Ying Yu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Ge Zhang
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Ya-Ning Mei
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Yu-Lan Lin
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fujian, China
| | - Chao-Lu Hasi
- Department of Laboratory Medicine, The First Hospital of Shanxi Medical University, Shanxi, China
| | - Sharon C A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Fan-Rong Kong
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Meng Xiao
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Ying-Chun Xu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Li Zhang
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
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Zeeshan M, Memon S, Malick A, Naqvi SF, Farooqi J, Ghanchi NK, Jabeen K. Fluconazole-resistant Candida parapsilosis complex candidemia and analysis of mutations in the ERG11 gene from Pakistan. Mycoses 2024; 67:e13677. [PMID: 37990393 DOI: 10.1111/myc.13677] [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: 07/24/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Recent reports of the emergence of fluconazole resistance in Candida parapsilosis species complex poses a challenge, more specifically in settings where echinocandin-based treatment regime is not feasible. OBJECTIVE This study reported emergence of fluconazole resistance in C. parapsilosis species complex strains isolated from blood cultures. MATERIALS AND METHODS This retrospective observational study was conducted from 2018 to 2020 at a tertiary care laboratory from Pakistan. Fluconazole-resistant C. parapsilosis species complex fungemia cases were identified from laboratory database and clinical details were collected. Identification of C. parapsilosis species complex was done using API 20C AUX and Cornmeal Tween80 agar morphology. Minimum inhibitory concentrations (MICs) were determined using Sensititre YeastONE and interpretation was done with CLSI M60 ED1:2017. ERG11 gene region was amplified and sequenced by Sanger sequencing and analysed by MEGA 11 Software. RESULTS A total of 13 (8.5%) fluconazole-resistant isolates were identified from 152 C. parapsilosis species complex candidemia cases. Fluconazole MICs of resistant isolates ranged between 8 and 256 μg/mL. Analysis of ERG11 gene revealed nonsynonymous mutations at position Y132F in 86% of the fluconazole-resistant isolates. Diabetes and hospitalization were important risk factors for candidemia with fluconazole-resistant C. parapsilosis complex. CONCLUSION This is the first report of the emergence and molecular mechanisms of fluconazole resistance in C. parapsilosis species complex from Pakistan. Y132F mutation in the ERG11 gene was the most common mutation in fluconazole-resistant strains. These findings are concerning and necessitate better diagnostics, newer antifungals, ongoing surveillance and further insights on resistance mechanisms in the country.
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Affiliation(s)
- Mohammad Zeeshan
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Saba Memon
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Ayesha Malick
- Aga Khan University Medical College, Karachi, Pakistan
| | - Syed Faheem Naqvi
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Joveria Farooqi
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Najia Karim Ghanchi
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Kauser Jabeen
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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Govrins M, Lass-Flörl C. Candida parapsilosis complex in the clinical setting. Nat Rev Microbiol 2024; 22:46-59. [PMID: 37674021 DOI: 10.1038/s41579-023-00961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
Representatives of the Candida parapsilosis complex are important yeast species causing human infections, including candidaemia as one of the leading diseases. This complex comprises C. parapsilosis, Candida orthopsilosis and Candida metapsilosis, and causes a wide range of clinical presentations from colonization to superficial and disseminated infections with a high prevalence in preterm-born infants and the potential to cause outbreaks in hospital settings. Compared with other Candida species, the C. parapsilosis complex shows high minimal inhibitory concentrations for echinocandin drugs due to a naturally occurring FKS1 polymorphism. The emergence of clonal outbreaks of strains with resistance to commonly used antifungals, such as fluconazole, is causing concern. In this Review, we present the latest medical data covering epidemiology, diagnosis, resistance and current treatment approaches for the C. parapsilosis complex. We describe its main clinical manifestations in adults and children and highlight new treatment options. We compare the three sister species, examining key elements of microbiology and clinical characteristics, including the population at risk, disease manifestation and colonization status. Finally, we provide a comprehensive resource for clinicians and researchers focusing on Candida species infections and the C. parapsilosis complex, aiming to bridge the emerging translational knowledge and future therapeutic challenges associated with this human pathogen.
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Affiliation(s)
- Miriam Govrins
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
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Byun JH, Won EJ, Cho HW, Kim D, Lee H, Kim SH, Choi MJ, Byun SA, Lee GY, Kee SJ, Kim TY, Kim MN, Choi JY, Yong D, Shin JH. Detection and Characterization of Two Phenotypes of Candida parapsilosis in South Korea: Clinical Features and Microbiological Findings. Microbiol Spectr 2023; 11:e0006623. [PMID: 37154762 PMCID: PMC10269542 DOI: 10.1128/spectrum.00066-23] [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: 01/20/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023] Open
Abstract
We newly detected two (sinking and floating) phenotypes of Candida parapsilosis among bloodstream infection (BSI) isolates from Korean hospitals and assessed their microbiological and clinical characteristics. During the performance of a Clinical and Laboratory Standards Institute (CLSI) broth microdilution antifungal susceptibility testing, the sinking phenotype had a characteristic smaller button-like appearance because all yeast cells sank to the bottoms of the CLSI U-shaped round-bottom wells, whereas the floating phenotype comprised dispersed cells. Phenotypic analysis, antifungal susceptibility testing, ERG11 sequencing, microsatellite genotyping, and clinical analysis were performed on C. parapsilosis isolates from 197 patients with BSI at a university hospital during 2006 to 2018. The sinking phenotype was detected in 86.7% (65/75) of the fluconazole-nonsusceptible (FNS) isolates, 92.9% (65/70) of the isolates harboring the Y132F ERG11 gene substitution, and 49.7% (98/197) of all isolates. Clonality was more frequently observed for the Y132F-sinking isolates (84.6% [55/65]) than for all other isolates (26.5% [35/132]; P < 0.0001). Annual incidence of Y132F-sinking isolates increased 4.5-fold after 2014, and two dominant genotypes, persistently recovered for 6 and 10 years, accounted for 69.2% of all Y132F-sinking isolates. Azole breakthrough fungemia (odds ratio [OR], 6.540), admission to the intensive care unit (OR, 5.044), and urinary catheter placement (OR, 6.918) were independent risk factors for BSIs with Y132F-sinking isolates. The Y132F-sinking isolates exhibited fewer pseudohyphae, a higher chitin content, and lower virulence in the Galleria mellonella model than the floating isolates. These long-term results illustrate the increasing BSIs caused by clonal transmission of the Y132F-sinking isolates of C. parapsilosis. IMPORTANCE We believe that this is the first study describe the microbiological and molecular characteristics of bloodstream isolates of C. parapsilosis in Korea exhibiting two phenotypes (sinking and floating). An important aspect of our findings is that the sinking phenotype was observed predominantly in isolates harboring a Y132F substitution in the ERG11 gene (92.9%), fluconazole-nonsusceptible (FNS) isolates (86.7%), and clonal BSI isolates (74.4%) of C. parapsilosis. Although the increase in the prevalence of FNS C. parapsilosis isolates has been a major threat in developing countries, in which the vast majority of candidemia cases are treated with fluconazole, our long-term results show increasing numbers of BSIs caused by clonal transmission of Y132F-sinking isolates of C. parapsilosis in the period with an increased echinocandin use for candidemia treatment in Korea, which suggests that C. parapsilosis isolates with the sinking phenotype continue to be a nosocomial threat in the era of echinocandin therapy.
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Affiliation(s)
- Jung-Hyun Byun
- Department of Laboratory Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Eun Jeong Won
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hae Weon Cho
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
- Department of Laboratory Medicine, Myongji Hospital, Goyang, South Korea
| | - Daewon Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Soo Hyun Kim
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Min Ji Choi
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Seung A. Byun
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Ga Yeong Lee
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Tae Yeul Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Dongeun Yong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
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