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Applying Diagnostic Stewardship to Proactively Optimize the Management of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11030308. [PMID: 35326771 PMCID: PMC8944608 DOI: 10.3390/antibiotics11030308] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/05/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
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Burillo A, Bouza E. Faster infection diagnostics for intensive care unit (ICU) patients. Expert Rev Mol Diagn 2022; 22:347-360. [PMID: 35152813 DOI: 10.1080/14737159.2022.2037422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : The patient admitted to intensive care units (ICU) is critically ill, to some extent immunosuppressed, with a high risk of infection, sometimes by multidrug-resistant microorganisms. In this context, the intensivist expects from the microbiology service quick and understandable information so that appropriate antimicrobial treatment for that particular patient and infection can be initiated. AREAS COVERED : In this review of recent literature (2015-2021), we identified diagnostic methods for the most prevalent infections in these patients through a search of the databases Pubmed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip, and Sumsearch using the terms: adult, clinical laboratory techniques, critical care, early diagnosis, microbiology, molecular diagnostic techniques, spectrometry and metagenomics. EXPERT OPINION : There has been an exponential surge in diagnostic systems used directly on blood and other samples to expedite microbial identification and antimicrobial susceptibility testing of pathogens. Few studies have thus far assessed their clinical impact; final outcomes will also depend on preanalytical and post-analytical factors. Besides, many of the resistance mechanisms cannot yet be detected with molecular techniques, which impairs the prediction of the actual resistance phenotype. Nonetheless, this is an exciting field with much yet to explore.
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Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Ciudad Universitaria, 28040 Madrid, Spain.,Gregorio Marañón Health Research Institute, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Ciudad Universitaria, 28040 Madrid, Spain.,Gregorio Marañón Health Research Institute, Doctor Esquerdo 46, 28007, Madrid, Spain.,CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Av. Monforte de Lemos 3-5, Pabellón 11, Planta, 28029 Madrid, Spain
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Gur'ev AS, Tigasson M, Shalatova OY, Rastopov SF, Bilozor A, Ivanova M, Volkov AY. Fast antibiotic susceptibility testing of urine microflora using a microbiological analyzer based on coherent fluctuation nephelometry. Braz J Microbiol 2022; 53:195-204. [PMID: 35025087 PMCID: PMC8882479 DOI: 10.1007/s42770-021-00671-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 12/24/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Traditional culture-based microbiological methods remain the most used for defining the etiology of urinary tract infections and antibiotic susceptibility testing (AST) of isolated uropathogens. They are time-consuming and lead to delays of several days when obtaining the final results of microbiological tests. OBJECTIVES In this study, we validate the possibility of using a microbiological CFN analyzer combined with MALDI-TOF mass spectrometry (MS) for fast conclusive urine testing (1 day) without obtaining pure cultures. MATERIALS AND METHODS The study included three stages: detection of urine microflora growth using the CFN analyzer to separate positive and negative samples within 2-4 h; fast MS identification of positive samples without isolating uropathogens; fast AST using CFN analyzer within 3-6 h. In parallel, all urine samples were tested by traditional culture-based microbiological methods. RESULT In total, 194 urine samples were tested, and 22 urine cultures were identified by MS, among them, 20 monocultures with bacterial counts ≥ 105 and 2 mixed cultures. The AST of these 22 urine cultures and additional 88 pure clinical cultures was performed using eight antibiotics. Overall, 276 tests were performed. The results of AST obtained using the CFN analyzer and traditional methods were in good agreement (98.2%). Although two mixed cultures were falsely identified as monocultures, their susceptibility determined by the CFN analyzer was correct. CONCLUSIONS The CFN analyzer is promising and effective for fast AST. Combined with MS identification, it allows to perform full urine analysis in 1 day without the lengthy isolation of pure cultures.
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Affiliation(s)
- Alexander S Gur'ev
- Scientific-Research Laboratory, M.F. Vladimirsky Moscow Regional Clinical and Research Institute (MONIKI), Shchepkina str. 61/2, b.1, 129110, Moscow, Russian Federation.
- Medtechnopark Ltd, Profsoyuznaya str. 8-2-383, 117292, Moscow, Russian Federation.
| | - Margus Tigasson
- Department of Microbiology, Central Laboratory, East-Tallinn Central Hospital, Ravi 18, 10138, Tallinn, Estonia
| | - Olga Yu Shalatova
- Laboratory of Biopreparations, Innovative Technologies Department, Pasteur Institute of Epidemiology and Microbiology, Mira str. 14, 197101, St. Petersburg, Russian Federation
| | - Stanislav F Rastopov
- Optical Spectroscopy Department, A.M. Prokhorov General Physics Institute of the Russian Academy of Sciences, Vavilov str. 38, 119991, Moscow, Russian Federation
| | - Anastasia Bilozor
- Department of Microbiology, Central Laboratory, East-Tallinn Central Hospital, Ravi 18, 10138, Tallinn, Estonia
| | - Marina Ivanova
- Department of Microbiology, Central Laboratory, East-Tallinn Central Hospital, Ravi 18, 10138, Tallinn, Estonia
| | - Alexey Yu Volkov
- Medtechnopark Ltd, Profsoyuznaya str. 8-2-383, 117292, Moscow, Russian Federation
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Rapid identification of uropathogens by combining Alfred 60 system with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry technology. Eur J Clin Microbiol Infect Dis 2020; 39:1855-1863. [PMID: 32388696 DOI: 10.1007/s10096-020-03919-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022]
Abstract
Rapid identification of uropathogens is needed to determine appropriate antimicrobial therapy. This study evaluated performance of the Alfred 60 system combined with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS) technology for rapid identification of uropathogens. The Alfred 60 system was used to screen urine cultures, followed by identifying the microbial pathogen in positive cultures using MALDI-TOF MS. The Alfred 60 detected positive cultures by measuring the turbidity of urine samples, which were transferred automatically to vials containing liquid medium and incubated for 3.5 h at 35 °C in the Alfred 60 system. Vials that showed growth were removed and centrifuged. The pellet was subjected to MALDI-TOF MS identification. In parallel, positive urine samples were inoculated onto agar plates for identification by conventional culture. The time required to detect positive urine cultures with Alfred 60 and identify the uropathogens with MALDI-TOF MS ranged from 15 min to 3.5 h. Among 146 positive urine samples tested, conventional cultures showed three culture groups: group 1 included 101 samples with growth of a single type of microorganism; group 2 included 34 samples with 2 types of microorganisms; and group 3 included 11 samples with ≥ 3 types of microorganisms. Direct identification by MALDI-TOF MS was concordant with 95% of the samples in group 1, 100% of the principal microorganism in group 2, but could not identify microorganisms in group 3. This combination of methods provides rapid, reliable microbial identification for most positive urine cultures.
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Anton-Vazquez V, Adjepong S, Suarez C, Planche T. Evaluation of a new Rapid Antimicrobial Susceptibility system for Gram-negative and Gram-positive bloodstream infections: speed and accuracy of Alfred 60AST. BMC Microbiol 2019; 19:268. [PMID: 31783787 PMCID: PMC6884782 DOI: 10.1186/s12866-019-1654-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 11/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blood stream infections (BSIs) are a major cause of morbidity and mortality. The time from taking blood cultures to obtain results of antibiotic sensitivity can be up to five days which impacts patient care. The Alfred 60 AST™ can reduce laboratory time from positive culture bottle to susceptibility results from 16 to 25 h to 5-6 h, transforming patient care. To evaluate the diagnostic accuracy of a rapid antimicrobial susceptibility system, the Alfred 60 AST™, in clinical isolates from patients with BSIs and confirm time to results. 301 Gram-negative and 86 Gram-positive isolates were analysed directly from positive blood culture bottles following Gram staining. Antimicrobial susceptibility results and time-to-results obtained by rapid Alfred 60 AST system and BD Phoenix were compared . RESULTS A total of 2196 antimicrobial susceptibility test results (AST) were performed: 1863 Gram-negative and 333 Gram-positive. AST categorical agreement (CA) for Alfred 60 AST™ was 95% (1772/1863) for Gram-negative and 89% (295/333) for Gram-positive isolates. Gram-negative CA: ampicillin 96% (290/301); ciprofloxacin 95% (283/297); ceftriaxone 96% (75/78); meropenem 97% (288/297); piperacillin-tazobactam 95% (280/295); gentamicin 94% (279/297) and amikacin 93% (277/298). The median time to susceptibility results from blood culture flagging positive was 6.3 h vs 20 h (p < 0.01) for Alfred system vs BD Phoenix™. CONCLUSION Alfred 60 AST system greatly reduced time to antimicrobial susceptibility results in Gram-negative and Gram-positive BSIs with good performance and cost, particularly for Gram-negative bacteraemia.
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Affiliation(s)
- Vanesa Anton-Vazquez
- St. George's University of London. Institute for Infection and Immunity, London, SW17 0RE, UK.
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
| | - Samuel Adjepong
- Department of Medical Microbiology, Southwest London Pathology, St. George's Hospital Blackshaw Road, London, SW17 0QT, UK
| | - Cristina Suarez
- St. George's University of London. Institute for Infection and Immunity, London, SW17 0RE, UK
| | - Timothy Planche
- St. George's University of London. Institute for Infection and Immunity, London, SW17 0RE, UK
- Department of Medical Microbiology, Southwest London Pathology, St. George's Hospital Blackshaw Road, London, SW17 0QT, UK
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
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A new rapid method for detecting extended-spectrum beta-lactamase/AmpC-producing Enterobacteriaceae directly from positive blood cultures using the Uro4 HB&L™ system. Braz J Microbiol 2019; 50:927-933. [DOI: 10.1007/s42770-019-00103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022] Open
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Herráez Carrera O, Huertas Vaquero M, Asencio Egea MA, Gaitán Pitera J, Carranza González R. [Economic evaluation of the Alfred 60/AST device implantation for bacterial growth detection with automatic sewing machine]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:73-77. [PMID: 30630308 PMCID: PMC6372960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/15/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE It is becoming increasingly necessary to automatize screening of urine samples to culture at Microbiology laboratories. Our objective was to estimate the budget threshold from which the Alfred 60/AST device would be profitable for our hospital. METHODS Cost minimization study by decision trees, carried out in a General Hospital. The cost of traditional urine culture and urine processing using Alfred-60/AST were compared. Traditional processing involves the culture of all urine specimens received onto blood and MacConkey agar, and identification of every microorganism isolated by Vitek-2 system. The autoanalyzer would only inoculate the positive urines onto a chromogenic media, directly identifying the Escherichia coli isolates. RESULTS The variables with the greatest economic impact in the model were the probability of obtaining a positive culture, the prevalence of E. coli in the urine cultures and the cost per sample using Alfred-60/AST. The multivariate sensitivity analysis showed that the model was solid. The bivariate sensitivity analysis showed that the model is suceptible to cost modification, mainly of the automatic device. At a threshold value of 1.40 euros/determination, the automatic processing would decrease the annual costs in 2,879 euros. CONCLUSIONS The introduction of the Alfred-60/AST device in our laboratory at 1.40 euros/determination would reduce urine processing workload, saving time and costs.
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Affiliation(s)
- O Herráez Carrera
- Oscar Herráez Carrera, Servicio de Análisis Clínicos. Unidad de Calidad. Hospital General La Mancha Centro, Avenida de la Constitución, 3 ; 13.600 Alcázar de San Juan (Ciudad Real) Spain.
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A Prospective Evaluation of Two Rapid Phenotypical Antimicrobial Susceptibility Technologies for the Diagnostic Stewardship of Sepsis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6976923. [PMID: 29862284 PMCID: PMC5971348 DOI: 10.1155/2018/6976923] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/29/2018] [Indexed: 12/11/2022]
Abstract
Rapid identification of bloodstream pathogens by MALDI-TOF MS and the recently introduced rapid antimicrobial susceptibility testing (rAST) directly from positive blood cultures allow clinicians to promptly achieve a targeted therapy, especially for multidrug resistant microorganisms. In the present study, we propose a comparison between phenotypical rASTs performed in light-scattering technology (Alfred 60AST, Alifax®) and fluorescence in situ hybridization (Pheno™, Accelerate) directly from positive blood cultures, providing results in 4–7 hours. Blood samples from 67 patients admitted to the Azienda Ospedaliero-Universitaria Pisana were analyzed. After the direct MALDI-TOF MS identification, the rAST was performed at the same time both on Alfred 60AST and Pheno. Alfred 60AST provided qualitative results, interpreted in terms of clinical categories (SIR). Pheno provided identification and MIC values for each antibiotic tested. Results were compared to the broth microdilution assay (SensiTitre™, Thermo Fisher Scientific), according to EUCAST rules. Using Alfred 60AST, an agreement was reached, 91.1% for Gram-negative and 95.7% for Gram-positive bacteria, while using Pheno, the agreement was 90.6% for Gram-negative and 100% for Gram-positive bacteria. Both methods provided reliable results; Alfred 60AST combined with MALDI-TOF MS proved itself faster and cheaper. Pheno provided identification and MIC determination in a single test and, although more expensive, may be useful whenever MIC value is necessary and where MALDI-TOF MS is not present.
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Barnini S, Brucculeri V, Morici P, Ghelardi E, Florio W, Lupetti A. A new rapid method for direct antimicrobial susceptibility testing of bacteria from positive blood cultures. BMC Microbiol 2016; 16:185. [PMID: 27520338 PMCID: PMC4982226 DOI: 10.1186/s12866-016-0805-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/04/2016] [Indexed: 11/29/2022] Open
Abstract
Background Rapid identification and antimicrobial susceptibility testing (AST) of the causative agent(s) of bloodstream infections can lead to prompt appropriate antimicrobial therapy. To shorten species identification, in this study bacteria were recovered from monomicrobial blood cultures by serum separator tubes and spotted onto the target plate for direct MALDI-TOF MS identification. Proper antibiotics were selected for direct AST based on species identification. In order to obtain rapid AST results, bacteria were recovered from positive blood cultures by two different protocols: by serum separator tubes (further referred to as PR1), or after a short-term subculture in liquid medium (further referred to as PR2). The results were compared with those obtained by the method currently used in our laboratory consisting in identification by MALDI-TOF and AST by Vitek 2 or Sensititre on isolated colonies. Results The direct MALDI-TOF method concordantly identified with the current method 97.5 % of the Gram-negative bacteria and 96.1 % of the Gram-positive cocci contained in monomicrobial blood cultures. The direct AST by PR1 and PR2 for all isolate/antimicrobial agent combinations was concordant/correct with the current method for 87.8 and 90.5 % of Gram-negative bacteria and for 93.1 and 93.8 % of Gram-positive cocci, respectively. In particular, 100 % categorical agreement was found with levofloxacin for Enterobacteriaceae by both PR1 and PR2, and 99.0 and 100 % categorical agreement was observed with linezolid for Gram-positive cocci by PR1 and PR2, respectively. There was no significant difference in accuracy between PR1 and PR2 for Gram-negative bacteria and Gram-positive cocci. Conclusions This newly described method seems promising for providing accurate AST results. Most importantly, these results would be available in a few hours from blood culture positivity, which would help clinicians to promptly confirm or streamline an effective antibiotic therapy in patients with bloodstream infections. Electronic supplementary material The online version of this article (doi:10.1186/s12866-016-0805-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Paola Morici
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | - Emilia Ghelardi
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | - Walter Florio
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | - Antonella Lupetti
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy.
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Evaluation of the SediMax automated microscopy sediment analyzer and the Sysmex UF-1000i flow cytometer as screening tools to rule out negative urinary tract infections. Clin Chim Acta 2016; 456:31-35. [DOI: 10.1016/j.cca.2016.02.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 11/20/2022]
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Coherent Fluctuation Nephelometry: A Rapid Method for Urine Screening for Bacterial Contamination. Bull Exp Biol Med 2015; 159:107-10. [PMID: 26028234 DOI: 10.1007/s10517-015-2902-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Indexed: 10/23/2022]
Abstract
Express-test by the method of coherent fluctuation nephelometry for urine contamination was carried out on two prototype instruments with standard polystyrene photometric cuvettes. We analyzed 209 and 119 urine samples. Due to high sensitivity of the method, up to 50% negative samples were detected within 10 min by initial opacity and 90% negative samples were detected during 3.5 h by registration of the bacterial growth curves.
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Reply to “Technical Notes on the Correct Configuration of the Alfred 60/AST Device for the Detection of Urinary Tract Infections”. J Clin Microbiol 2014; 52:1807. [DOI: 10.1128/jcm.00356-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Technical notes on the correct configuration of the Alfred 60/AST device for the detection of urinary tract infections. J Clin Microbiol 2014; 52:1805-6. [PMID: 24744406 DOI: 10.1128/jcm.03241-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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