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Bruyneel A, Miesse I, Mathieu D, Djuidjé Yuemo C, Simon A. Prevalence and factors associated with methicillin-resistant Staphylococcus aureus colonization on admission to geriatric care units: impact on screening practices. J Hosp Infect 2024; 146:109-115. [PMID: 38309666 DOI: 10.1016/j.jhin.2024.01.014] [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: 10/27/2023] [Revised: 01/04/2024] [Accepted: 01/14/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVES Universal screening for methicillin-resistant Staphylococcus aureus (MRSA) entails additional costs, and there is no consensus for targeted screening for high-risk units. The aims of this study were to determine the prevalence of MRSA in geriatric care units, and to identify the factors associated with MRSA colonization on admission. METHODS This retrospective case-control study (1:1) in the geriatric care unit of six Belgian hospitals covered the period from 1st January 2021 to 31st December 2022. Cases were patients with a positive MRSA screening result within 48 h of admission to the geriatric care unit, and controls were patients with a negative screening result. RESULTS In total, 556 patients were included in this study (278 in each group). Prevalence per 100 admissions for the total sample was 2.3 [95% confidence interval (CI) 2.2-2.6]. Significant multi-variate factors associated with MRSA carriage on admission were: history of MRSA, nursing home origin, and chronic skin lesions. Applying these three factors would give an area under the receiver operating characteristic (ROC) curve of 0.73 (95% CI 0.71-0.77), and would allow screening to be carried out in only 55.4% of cases (95% CI 51.2-59.6%). CONCLUSIONS Using these factors as screening criteria in geriatric care units could significantly reduce the number of patients screened for MRSA, while maintaining satisfactory sensitivity and specificity.
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Affiliation(s)
- A Bruyneel
- Hospital Outbreak Support Team, Réseau Hospitalier Universitaire Cœur de Wallonie, Belgium; Health Economics, Hospital Management and Nursing Research Department, School of Public Health, Université Libre de Bruxelles, Belgium.
| | - I Miesse
- Hospital Outbreak Support Team, Réseau Hospitalier Universitaire Cœur de Wallonie, Belgium
| | - D Mathieu
- Hospital Outbreak Support Team, Réseau Hospitalier Universitaire Cœur de Wallonie, Belgium; Infectiology - Infection Prevention and Control Department, CHU Tivoli, La Louviere, Belgium
| | | | - A Simon
- Infection Control Team, CHU HELORA, Belgium
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Callejón Fernández M, Abreu Rodríguez R, Arias Á, Aguirre-Jaime A, Castro Hernández MB, Ramos Real MJ, Pedroso Fernández Y, Lecuona M. The Impact of MRSA Colonization on Healthcare-Associated Infections in Long-Term Care Facility Residents: A Whole-Genome Sequencing-Based Study. Microorganisms 2023; 11:2842. [PMID: 38137985 PMCID: PMC10745794 DOI: 10.3390/microorganisms11122842] [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: 10/23/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) colonization has been considered a risk factor for the development of infection, however, there are no studies that have compared the colonizing and infecting strains using whole-genome sequencing (WGS). The aim of this study is to determine the prevalence of and risk factors for MRSA colonization among long-term care facilities (LTCF) residents of Tenerife (Spain), and to analyze the epidemiological relationship between the colonizing and infecting strains using WGS. A point-prevalence study was carried out at 14 LTCFs in Tenerife from October 2020 to May 2021. Nasal swabs were cultured for MRSA. Colonized residents were followed up for two years. A phylogenetic comparison between colonization and infection strains was performed using WGS. A total of 764 residents were included. The prevalence of colonization by MRSA was 28.1% (n = 215), of which 12 (5.6%) subsequently developed infection. A close genetic relationship between colonization and infection isolates was found in three of the four (75%) residents studied. Our study confirms that colonized residents can develop serious MRSA infections from the same nasal colonization strain. Given the high prevalence of MRSA colonization in these centers, it is necessary to implement strategies with preventive measures to avoid the development of infection and the transmission of MRSA.
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Affiliation(s)
- Manuel Callejón Fernández
- Microbiology and Infection Control Service, University Hospital of the Canary Island (HUC), 38320 La Laguna, Spain; (M.B.C.H.); (M.J.R.R.); (Y.P.F.); (M.L.)
- Doctoral Program in Medical and Pharmaceutical Sciences, Development and Quality of Life, University of La Laguna (ULL), Campus de Ofra s/n, 38071 Santa Cruz de Tenerife, Spain
| | - Rossana Abreu Rodríguez
- Department of Preventive Medicine and Public Health, University of La Laguna (ULL), Campus de Ofra s/n, 38200 Santa Cruz de Tenerife, Spain; (R.A.R.); (Á.A.)
| | - Ángeles Arias
- Department of Preventive Medicine and Public Health, University of La Laguna (ULL), Campus de Ofra s/n, 38200 Santa Cruz de Tenerife, Spain; (R.A.R.); (Á.A.)
| | - Armando Aguirre-Jaime
- Institute of Care Research, Nurses Association of Santa Cruz de Tenerife, C. San Martin, 63, 38001 Santa Cruz de Tenerife, Spain;
| | - María Beatriz Castro Hernández
- Microbiology and Infection Control Service, University Hospital of the Canary Island (HUC), 38320 La Laguna, Spain; (M.B.C.H.); (M.J.R.R.); (Y.P.F.); (M.L.)
| | - María José Ramos Real
- Microbiology and Infection Control Service, University Hospital of the Canary Island (HUC), 38320 La Laguna, Spain; (M.B.C.H.); (M.J.R.R.); (Y.P.F.); (M.L.)
| | - Yanet Pedroso Fernández
- Microbiology and Infection Control Service, University Hospital of the Canary Island (HUC), 38320 La Laguna, Spain; (M.B.C.H.); (M.J.R.R.); (Y.P.F.); (M.L.)
| | - María Lecuona
- Microbiology and Infection Control Service, University Hospital of the Canary Island (HUC), 38320 La Laguna, Spain; (M.B.C.H.); (M.J.R.R.); (Y.P.F.); (M.L.)
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Hasanpour AH, Sepidarkish M, Mollalo A, Ardekani A, Almukhtar M, Mechaal A, Hosseini SR, Bayani M, Javanian M, Rostami A. The global prevalence of methicillin-resistant Staphylococcus aureus colonization in residents of elderly care centers: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2023; 12:4. [PMID: 36709300 PMCID: PMC9884412 DOI: 10.1186/s13756-023-01210-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 01/21/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a difficult to treat infection, particularly in residents of elderly care centers (ECCs). Despite the substantial burden of MRSA, an inadequate number of studies have analyzed MRSA prevalence in ECCs. OBJECTIVES We conducted a worldwide systematic review and meta-analysis on the prevalence and risk factors of MRSA in ECCs. METHODS We searched MEDLINE/PubMed, EMBASE, Web of Science, and Scopus databases and the gray literature sources for all studies published between January 1980 and December 2022 on the prevalence of MRSA in ECCs. A random-effects model was utilized to estimate pooled prevalence rates at 95% confidence intervals (CI). Moreover, the data were analyzed based on World Health Organization-defined regions, income, and human development index levels. RESULTS In total, 119 studies, including 164,717 participants from 29 countries, were found eligible for meta-analysis. The pooled global prevalence of MRSA was 14.69% (95% CI 12.39-17.15%; 16,793/164,717). Male gender [prevalence ratio (PR) = 1.55; 95% CI 1.47-1.64], previous MRSA infection (PR = 3.71; 95% CI 3.44-4.01), prior use of antibiotics (PR = 1.97; 95% CI 1.83-2.12), hospitalized within the previous year (PR = 1.32; 95% CI 1.20-1.45), have had any wound (PR = 2.38; 95% CI 2.23-2.55), have used urinary catheter (PR = 2.24; 95% CI 2.06-2.43), have used any medical device (PR = 1.78; 95% CI 1.66-1.91), and those with diabetes (PR = 1.55; CI 1.43-1.67) were more likely to be colonized by MRSA than other patients. CONCLUSION Screening programs and preventive measures should target MRSA in ECCs due to the high global prevalence rates.
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Affiliation(s)
- Amir Hossein Hasanpour
- grid.411495.c0000 0004 0421 4102Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Mahdi Sepidarkish
- grid.411495.c0000 0004 0421 4102Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
| | - Abolfazl Mollalo
- grid.252749.f0000 0001 1261 1616Department of Public Health and Prevention Science, School of Health Sciences, Baldwin Wallace University, Berea, OH USA
| | - Ali Ardekani
- grid.412571.40000 0000 8819 4698School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Amal Mechaal
- grid.240145.60000 0001 2291 4776Department of Hematopoietic Biology and Malignancy, The University of Texas Md Anderson Cancer Center, Houston, TX USA
| | - Seyed Reza Hosseini
- grid.411495.c0000 0004 0421 4102Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Masoumeh Bayani
- grid.411495.c0000 0004 0421 4102Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mostafa Javanian
- grid.411495.c0000 0004 0421 4102Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Ali Rostami
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
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Molecular and Source-Specific Profiling of Hospital Staphylococcus aureus Reveal Dominance of Skin Infection and Age-Specific Selections in Pediatrics and Geriatrics. Microorganisms 2023; 11:microorganisms11010149. [PMID: 36677441 PMCID: PMC9862673 DOI: 10.3390/microorganisms11010149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/24/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
Staphylococcus aureus is a major human-associated pathogen that causes a wide range of clinical infections. However, the increased human dynamics and the changing epidemiology of the species have made it imperative to understand the population structure of local ecotypes, their transmission dynamics, and the emergence of new strains. Since the previous methicillin-resistant S. aureus (MRSA) pandemic, there has been a steady increase in global healthcare-associated infections involving cutaneous and soft tissue and resulting in high morbidities and mortalities. Limited data and paucity of high-quality evidence exist for many key clinical questions about the pattern of S. aureus infections. Using clinical, molecular, and epidemiological characterizations of isolates, hospital data on age and infection sites, as well as antibiograms, we have investigated profiles of circulating S. aureus types and infection patterns. We showed that age-specific profiling in both intensive care unit (ICU) and non-ICU revealed highest infection rates (94.7%) in senior-patients > 50 years; most of which were MRSA (81.99%). However, specific distributions of geriatric MRSA and MSSA rates were 46.5% and 4.6% in ICU and 35.48% and 8.065% in non-ICU, respectively. Intriguingly, the age groups 0−20 years showed uniquely similar MRSA patterns in ICU and non-ICU patients (13.9% and 9.7%, respectively) and MSSA in ICU (11.6%). The similar frequencies of both lineages in youth at both settings is consistent with their increased socializations and gathering strongly implying carriage and potential evolutionary replacement of MSSA by MRSA. However, in age groups 20−50 years, MRSA was two-fold higher in non-ICU (35%) than ICU (18.6%). Interestingly, a highly significant association was found between infection-site and age-groups (p-value 0.000). Skin infections remained higher in all ages; pediatrics 32.14%, adults 56%, and seniors 25% while respiratory infections were lower in pediatrics (14.3%) and adults (17%) while it was highest in seniors (38%). Blood and “other” sites in pediatrics were recorded (28.6%; 25%, respectively), and were slightly lower in adults (18.6%; 8.6%) and seniors (14%; 22.8%), respectively. Furthermore, a significant association existed between infection-site and MRSA (Chi-Square Test, p-value 0.002). Thus, the common cutaneous infections across all age-groups imply that skin is a significant reservoir for endogenous infections; particularly, for geriatrics MRSA. These findings have important clinical implications and in understanding S. aureus profiles and transmission dynamics across different age groups that is necessary for strategic planning in patient management and infection control.
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Laupland KB. Preventing healthcare-related infections among older adults: a focus on cross-transmission of antibiotic-resistant bacteria. Expert Rev Anti Infect Ther 2022; 20:1171-1178. [PMID: 35793840 DOI: 10.1080/14787210.2022.2099375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Older individuals (i.e. age ≥65 years) are at increased risk for development of infections including those due to antimicrobial-resistant bacteria, and transmission may occur between institutional and community settings. AREAS COVERED This article reviews infections in older individuals with a specific focus on healthcare-related and antimicrobial resistant infections. A structured narrative review was performed to identify articles published in English since 2010. Themes included defining the scope of the problem, establishing characteristics of older individuals that impact the burden of resistant infections, and interventions aimed at minimizing their impact. EXPERT OPINION Older individuals suffer a high burden of illness related to antimicrobial resistant infections. Individuals with chronic illnesses, frailty, and residents of nursing homes are at highest risk. Clinical trials have shown that antimicrobial stewardship interventions may reduce antibiotic use in nursing homes without compromising safety. Antimicrobial resistant bacteria are prevalent among nursing home residents, and bundled infection prevention and control interventions can reduce their transmission. Transmission of antimicrobial resistant bacteria occurs among older adults across hospital and institutional settings, which may further spread to the community. The burden of infections in older adults is expected to increase in the coming years and represents a healthcare and research priority.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia
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Akine D, Sasahara T, Kiga K, Ae R, Kosami K, Yoshimura A, Kubota Y, Sasaki K, Kimura Y, Ogawa M, Watanabe S, Morisawa Y, Cui L. Distribution of Extended-Spectrum β-Lactamase Genes and Antimicrobial Susceptibility among Residents in Geriatric Long-Term Care Facilities in Japan. Antibiotics (Basel) 2021; 11:antibiotics11010036. [PMID: 35052913 PMCID: PMC8773109 DOI: 10.3390/antibiotics11010036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022] Open
Abstract
A high prevalence of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) may call for monitoring in geriatric long-term care facilities (g-LTCFs). We surveyed the distribution of ESBL-causative gene types and antimicrobial susceptibility in ESBL-PE strains from residents in g-LTCFs, and investigated the association between ESBL-causative gene types and antimicrobial susceptibility. First, we analyzed the types of ESBL-causative genes obtained from 141 ESBL-PE strains collected from the feces of residents in four Japanese g-LTCFs. Next, we determined the minimum inhibitory concentration values for alternative antimicrobial agents against ESBL-PE, including β-lactams and non-β-lactams. Escherichia coli accounted for 96% of the total ESBL-PE strains. Most strains (94%) contained blaCTX-M group genes. The genes most commonly underlying resistance were of the blaCTX-M-9 and blaCTX-M-1 groups. Little difference was found in the distribution of ESBL-causative genes among the facilities; however, antimicrobial susceptibility differed widely among the facilities. No specific difference was found between antimicrobial susceptibility and the number of ESBL-causative genes. Our data showed that ESBL-PEs were susceptible to some antimicrobial agents, but the susceptibility largely differed among facilities. These findings suggest that each g-LTCF may require specific treatment strategies based on their own antibiogram. Investigations into drug resistance should be performed in g-LTCFs as well as acute medical facilities.
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Affiliation(s)
- Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Teppei Sasahara
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
- Correspondence: (T.S.); (R.A.); Tel.: +81-285-58-7580 (T.S.)
| | - Kotaro Kiga
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
- Correspondence: (T.S.); (R.A.); Tel.: +81-285-58-7580 (T.S.)
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Hishimachi 3 chome, Kiryu 376-0001, Gunma, Japan;
| | - Yoshinari Kubota
- Nikko Citizen’s Hospital, Kiyotakiarasawamachi 1752-10, Nikko 321-1441, Tochigi, Japan;
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Shinya Watanabe
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Yuji Morisawa
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
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Ae R, Sasahara T, Yoshimura A, Kosami K, Hatakeyama S, Sasaki K, Kimura Y, Akine D, Ogawa M, Hamabata K, Cui L. Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities. Sci Rep 2021; 11:21607. [PMID: 34732819 PMCID: PMC8566574 DOI: 10.1038/s41598-021-01190-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 10/25/2021] [Indexed: 11/09/2022] Open
Abstract
Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.
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Affiliation(s)
- Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Teppei Sasahara
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan. .,Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Kiryu, Gunma, 376-0001, Japan
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shuji Hatakeyama
- Division of Infectious Diseases, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan.,Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kenji Hamabata
- Gerontological Nursing, School of Nursing, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
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