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Chitra S, Hinahara J, Goss TF, Gunter K, LaPensee K. Health-Related Quality of Life as Measured by the 36-Item Short Form Survey Among Adults With Acute Bacterial Skin and Skin Structure Infections who Received Either Omadacycline or Linezolid in a Phase 3 Double-Blind, Double-Dummy Clinical Trial. Open Forum Infect Dis 2021; 8:ofab459. [PMID: 34692889 PMCID: PMC8530258 DOI: 10.1093/ofid/ofab459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022] Open
Abstract
This analysis of data from a Phase 3 study of adults with acute bacterial skin and skin structure infections showed that successful oral treatment with omadacycline (n = 368) or linezolid (n = 367) was associated with improvement in health-related quality of life.
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Affiliation(s)
- Surya Chitra
- Paratek Pharmaceuticals, Inc., King of Prussia, Pennsylvania, USA
| | - Jordan Hinahara
- Boston Healthcare Associates, Inc., Boston, Massachusetts, USA
| | - Thomas F Goss
- Boston Healthcare Associates, Inc., Boston, Massachusetts, USA
| | - Kyle Gunter
- Paratek Pharmaceuticals, Inc., King of Prussia, Pennsylvania, USA
| | - Kenneth LaPensee
- Paratek Pharmaceuticals, Inc., King of Prussia, Pennsylvania, USA
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Malige A, Lands V, Matullo KS. The Clinical Utility of Maceration Dressings in the Treatment of Inpatient Hand Infections: An Evaluation of Treatment Outcomes Compared to Standard Care. Hand (N Y) 2021; 16:223-229. [PMID: 31165641 PMCID: PMC8041413 DOI: 10.1177/1558944719852744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: In cases of oral antibiotic-resistant infection of the hand, we propose utilizing a heated, moist maceration dressing to help shorten and simplify the in-hospital clinical course by increasing the efficacy of antibiotic deliverance to infection sites, increasing the success of nonoperative management, and decreasing eradication time of infection of the hand. Methods: Fifty-six patients older than 18 years of age who presented with hand infections requiring inpatient intravenous antibiotics at our suburban academic hospital over a 30-month period were included and randomly assigned to either the maceration dressing group or the standard treatment group. Maceration dressings included warm and moist gauze, kerlix, webril, Orthoglass, Aqua K Pad, and sling. Results: Fifty-two patients who were mostly male and younger than 60 years of age were included. Patients who used the maceration dressing had significantly shorter hospital lengths of stay (P = .02) and intravenous antibiotics duration before transition to oral antibiotics (P = .04), and decreased need for formal operating room irrigation and debridement to obtain source control (P = .02) compared to patients treated with the standard dressing. Post-hoc analysis yielded improved outcomes when using the maceration dressing regardless of whether initial bedside incision and drainage was needed to decompress a superficial abscess or not. Conclusion: The maceration dressing can be used along with proper intravenous antibiotic treatment to improve the treatment course of patients with hand infections regardless of whether the patient needs an initial bedside incision and drainage or not. Level of Evidence: Therapeutic Level II.
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Affiliation(s)
- Ajith Malige
- St. Luke’s University Health Network, Bethlehem, PA, USA,Ajith Malige, Department of Orthopaedic Surgery, St. Luke’s University Hospital, St. Luke’s University Health Network, PPHP 2, 801 Ostrum Street, Bethlehem, PA 18015, USA.
| | - Vince Lands
- St. Luke’s University Health Network, Bethlehem, PA, USA
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Cranendonk DR, Hugenholtz F, Prins JM, Savelkoul PHM, Budding AE, Wiersinga WJ. The Skin Microbiota in Patients Hospitalized for Cellulitis and Association With Outcome. Clin Infect Dis 2020; 68:1292-1299. [PMID: 30321312 DOI: 10.1093/cid/ciy709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 08/17/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The skin microbiota plays a key role in the pathogenesis of several skin diseases, but its role in cellulitis remains unknown. We investigated the skin microbiota in patients with cellulitis, studied whether its analysis could help determine the causative pathogen, and explored whether skin microbiota composition was associated with clinical outcomes. METHODS We prospectively included 58 patients hospitalized for cellulitis. Skin swabs obtained from the lesion sites were compared with swabs from identical sites on the contralateral unaffected limbs and with swabs obtained from 19 age- and sex-matched control subjects without cellulitis. Bacterial profiling of the skin microbiota was performed by interspacer profiling (IS-pro). RESULTS A large interpersonal variation in the skin microbiota composition of patients hospitalized with cellulitis was observed. Firmicutes were the dominant phylum, and Staphylococcus and Streptococcus the dominant genera. In most patients, a strong correlation between the microbiota of the affected lesion and the microbiota of the unaffected, contralateral limb was seen. Overall, the composition of the cellulitis microbiota could not be distinguished from the skin microbiota of controls. No consistent association could be found between traditional culture results and skin microbiota signatures in patients with cellulitis. Lastly, we found that neither microbiota composition nor diversity were associated with clinical parameters and outcomes in patients with cellulitis. CONCLUSIONS In this exploratory study on the skin microbiota in patients hospitalized with cellulitis, we were unable to identify a typical cellulitis microbiota. The diagnostic and prognostic information that could be derived from skin microbiota profiling in this patient cohort was limited. CLINICAL TRIALS REGISTRATION NCT02032654.
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Affiliation(s)
- Duncan R Cranendonk
- Center for Experimental and Molecular Medicine, University of Amsterdam.,Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
| | - Floor Hugenholtz
- Center for Experimental and Molecular Medicine, University of Amsterdam
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
| | - Paul H M Savelkoul
- Department of Medical Microbiology and Infection Control, VU University Medical Center, VU University, Amsterdam.,Department of Medical Microbiology, Maastricht University Medical Center, the Netherlands
| | - Andries E Budding
- Department of Medical Microbiology and Infection Control, VU University Medical Center, VU University, Amsterdam
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, University of Amsterdam.,Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
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Brindle RJ, O’Neill LA, Williams OM. Risk, Prevention, Diagnosis, and Management of Cellulitis and Erysipelas. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00287-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cranendonk DR, Opmeer BC, van Agtmael MA, Branger J, Brinkman K, Hoepelman AIM, Lauw FN, Oosterheert JJ, Pijlman AH, Sankatsing SUC, Soetekouw R, Veenstra J, de Vries PJ, Prins JM, Wiersinga WJ. Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis: a multicentre randomized, double-blind, placebo-controlled, non-inferiority trial. Clin Microbiol Infect 2019; 26:606-612. [PMID: 31618678 DOI: 10.1016/j.cmi.2019.09.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate whether antibiotic treatment of 6 days' duration is non-inferior to treatment for 12 days in patients hospitalized for cellulitis. METHODS This multicentre, randomized, double-blind, placebo-controlled, non-inferiority trial enrolled adult patients hospitalized for severe cellulitis who were treated with intravenous flucloxacillin. At day 6 participants with symptom improvement who were afebrile were randomized between an additional 6 days of oral flucloxacillin or placebo in a 1:1 ratio, stratified for diabetes and hospital. The primary outcome was cure by day 14, without relapse by day 28. Secondary outcomes included a modified cure assessment and relapse rate by day 90. RESULTS Between August 2014 and June 2017, 151 of 248 included participants were randomized. The intention-to-treat population consisted of 76 and 73 participants allocated to 12 and 6 days of antibiotic therapy, respectively (mean age 62 years, 67% males, 24% diabetics); 38/76 (50.0%) and 36/73 (49.3%) were cured in the 12- and 6-day groups respectively (ARR 0.7 percentage points, 95%CI: -15.0 to 16.3). Cure rates were 56/76 (73.7%) and 49/73 (67.1%) with the modified cure assessment (ARR 6.6, 95%CI: -8.0 to 20.8). After initial cure without relapse, day 90 relapse rates were higher in the 6-day group (6% versus 24%, p < 0.05). CONCLUSIONS Given the wide confidence intervals, we can neither confirm nor refute our hypothesis that 6 days of therapy is non-inferior to 12 days of therapy. However, a 6-day course resulted in significantly more frequent relapses by day 90. These findings require confirmation in future studies.
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Affiliation(s)
- D R Cranendonk
- Amsterdam UMC, University of Amsterdam, Department of Medicine, Division of Infectious Diseases, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Centre for Experimental and Molecular Medicine, Amsterdam Infection & Immunity Institute, Amsterdam, the Netherlands.
| | - B C Opmeer
- Amsterdam UMC, University of Amsterdam, Clinical Research Unit, Amsterdam, the Netherlands
| | - M A van Agtmael
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Amsterdam, the Netherlands
| | - J Branger
- Department of Internal Medicine, Flevoziekenhuis, Almere, the Netherlands
| | - K Brinkman
- Department of Internal Medicine, OLVG-Oost, Amsterdam, the Netherlands
| | - A I M Hoepelman
- Department of Internal Medicine, University Medical Centre, University of Utrecht, Utrecht, the Netherlands
| | - F N Lauw
- Department of Internal Medicine, MC Slotervaart, Amsterdam, the Netherlands
| | - J J Oosterheert
- Department of Internal Medicine, University Medical Centre, University of Utrecht, Utrecht, the Netherlands
| | - A H Pijlman
- Department of Internal Medicine, St Antonius Ziekenhuis, Utrecht, the Netherlands
| | - S U C Sankatsing
- Department of Internal Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | - R Soetekouw
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem, the Netherlands
| | - J Veenstra
- Department of Internal Medicine, OLVG-West, Amsterdam, the Netherlands
| | - P J de Vries
- Department of Internal Medicine, Tergooiziekenhuizen, Hilversum, the Netherlands
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Department of Medicine, Division of Infectious Diseases, Amsterdam, the Netherlands
| | - W J Wiersinga
- Amsterdam UMC, University of Amsterdam, Department of Medicine, Division of Infectious Diseases, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Centre for Experimental and Molecular Medicine, Amsterdam Infection & Immunity Institute, Amsterdam, the Netherlands
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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Clarke MC, Cheng AC, Pollard JG, Birch M, Cowan RU, Linke JA, Walton AL, Friedman ND. Lessons Learned From a Randomized Controlled Trial of Short-Course Intravenous Antibiotic Therapy for Erysipelas and Cellulitis of the Lower Limb (Switch Trial). Open Forum Infect Dis 2019; 6:ofz335. [PMID: 31660410 PMCID: PMC6798252 DOI: 10.1093/ofid/ofz335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/16/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. METHODS This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7-10 days' duration for the treatment of lower limb cellulitis. RESULTS Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17-40) hours, and in the ≥72-hour group it was 78 (41.5-210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. CONCLUSIONS The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. AUSTRALIA COUNCIL OF CLINICAL TRIALS REGISTRY NO ACTRN12613001366741.
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Affiliation(s)
- Marcus C Clarke
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Gd Pollard
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- Hospital in the Home Service, Barwon Health, Geelong, Victoria, Australia
| | - Mark Birch
- Department of Infectious Diseases, Christchurch Public Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Raquel U Cowan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Jake A Linke
- Deakin University, School of Medicine, Geelong, Victoria, Australia
| | - Aaron L Walton
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
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Abel Zur Wiesch P, Abel S, Gkotzis S, Ocampo P, Engelstädter J, Hinkley T, Magnus C, Waldor MK, Udekwu K, Cohen T. Classic reaction kinetics can explain complex patterns of antibiotic action. Sci Transl Med 2016; 7:287ra73. [PMID: 25972005 DOI: 10.1126/scitranslmed.aaa8760] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Finding optimal dosing strategies for treating bacterial infections is extremely difficult, and improving therapy requires costly and time-intensive experiments. To date, an incomplete mechanistic understanding of drug effects has limited our ability to make accurate quantitative predictions of drug-mediated bacterial killing and impeded the rational design of antibiotic treatment strategies. Three poorly understood phenomena complicate predictions of antibiotic activity: post-antibiotic growth suppression, density-dependent antibiotic effects, and persister cell formation. We show that chemical binding kinetics alone are sufficient to explain these three phenomena, using single-cell data and time-kill curves of Escherichia coli and Vibrio cholerae exposed to a variety of antibiotics in combination with a theoretical model that links chemical reaction kinetics to bacterial population biology. Our model reproduces existing observations, has a high predictive power across different experimental setups (R(2) = 0.86), and makes several testable predictions, which we verified in new experiments and by analyzing published data from a clinical trial on tuberculosis therapy. Although a variety of biological mechanisms have previously been invoked to explain post-antibiotic growth suppression, density-dependent antibiotic effects, and especially persister cell formation, our findings reveal that a simple model that considers only binding kinetics provides a parsimonious and unifying explanation for these three complex, phenotypically distinct behaviours. Current antibiotic and other chemotherapeutic regimens are often based on trial and error or expert opinion. Our "chemical reaction kinetics"-based approach may inform new strategies, which are based on rational design.
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Affiliation(s)
- Pia Abel Zur Wiesch
- Division of Global Health Equity, Brigham and Women's Hospital and Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA. Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA.
| | - Sören Abel
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA. Department of Pharmacy, UiT, The Arctic University of Norway, 9037 Tromsø, Norway
| | - Spyridon Gkotzis
- Department of Neuroscience, Karolinska Institutet, Retzius väg 8, 17177 Stockholm, Sweden
| | - Paolo Ocampo
- Institute of Integrative Biology, ETH Zürich, Universitätsstrasse 16, 8092 Zürich, Switzerland. Department of Environmental Microbiology, EAWAG, Überlandstrasse 133, 8600 Dübendorf, Switzerland
| | - Jan Engelstädter
- School of Biological Sciences, University of Queensland, Brisbane, Queensland 4072, Australia
| | - Trevor Hinkley
- School of Chemistry, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Carsten Magnus
- Institute of Medical Virology, University of Zürich, Winterthurerstrasse 190, 8057 Zürich, Switzerland
| | - Matthew K Waldor
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA. Howard Hughes Medical Institute, 181 Longwood Avenue, Boston, MA 02115, USA
| | - Klas Udekwu
- Department of Neuroscience, Karolinska Institutet, Retzius väg 8, 17177 Stockholm, Sweden
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women's Hospital and Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA. Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA. Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
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