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Martinecz A, Boeree MJ, Diacon AH, Dawson R, Hemez C, Aarnoutse RE, Abel Zur Wiesch P. High rifampicin peak plasma concentrations accelerate the slow phase of bacterial decline in tuberculosis patients: Evidence for heteroresistance. PLoS Comput Biol 2023; 19:e1011000. [PMID: 37053266 PMCID: PMC10128972 DOI: 10.1371/journal.pcbi.1011000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/25/2023] [Accepted: 03/06/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Antibiotic treatments are often associated with a late slowdown in bacterial killing. This separates the killing of bacteria into at least two distinct phases: a quick phase followed by a slower phase, the latter of which is linked to treatment success. Current mechanistic explanations for the in vitro slowdown are either antibiotic persistence or heteroresistance. Persistence is defined as the switching back and forth between susceptible and non-susceptible states, while heteroresistance is defined as the coexistence of bacteria with heterogeneous susceptibilities. Both are also thought to cause a slowdown in the decline of bacterial populations in patients and therefore complicate and prolong antibiotic treatments. Reduced bacterial death rates over time are also observed within tuberculosis patients, yet the mechanistic reasons for this are unknown and therefore the strategies to mitigate them are also unknown. METHODS AND FINDINGS We analyse a dose ranging trial for rifampicin in tuberculosis patients and show that there is a slowdown in the decline of bacteria. We show that the late phase of bacterial killing depends more on the peak drug concentrations than the total drug exposure. We compare these to pharmacokinetic-pharmacodynamic models of rifampicin heteroresistance and persistence. We find that the observation on the slow phase's dependence on pharmacokinetic measures, specifically peak concentrations are only compatible with models of heteroresistance and incompatible with models of persistence. The quantitative agreement between heteroresistance models and observations is very good ([Formula: see text]). To corroborate the importance of the slowdown, we validate our results by estimating the time to sputum culture conversion and compare the results to a different dose ranging trial. CONCLUSIONS Our findings indicate that higher doses, specifically higher peak concentrations may be used to optimize rifampicin treatments by accelerating bacterial killing in the slow phase. It adds to the growing body of literature supporting higher rifampicin doses for shortening tuberculosis treatments.
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Affiliation(s)
- Antal Martinecz
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Martin J Boeree
- Department of Lung Diseases, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - Andreas H Diacon
- Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Colin Hemez
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Graduate program in Biophysics, Harvard University, Boston, Massachusetts, United States of America
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Pia Abel Zur Wiesch
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, Pennsylvania, United States of America
- Department of Biology, Eberly College of Science, The Pennsylvania State University, University Park, Pennsylvania, United States of America
- Norwegian Institute of Public Health (Folkehelseinstitutt), Oslo, Norway
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2
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Rodríguez‐Pastor R, Shafran Y, Knossow N, Gutiérrez R, Harrus S, Zaman L, Lenski RE, Barrick JE, Hawlena H. A road map for in vivo evolution experiments with blood-borne parasitic microbes. Mol Ecol Resour 2022; 22:2843-2859. [PMID: 35599628 PMCID: PMC9796859 DOI: 10.1111/1755-0998.13649] [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: 11/07/2021] [Revised: 03/14/2022] [Accepted: 05/13/2022] [Indexed: 01/07/2023]
Abstract
Laboratory experiments in which blood-borne parasitic microbes evolve in their animal hosts offer an opportunity to study parasite evolution and adaptation in real time and under natural settings. The main challenge of these experiments is to establish a protocol that is both practical over multiple passages and accurately reflects natural transmission scenarios and mechanisms. We provide a guide to the steps that should be considered when designing such a protocol, and we demonstrate its use via a case study. We highlight the importance of choosing suitable ancestral genotypes, treatments, number of replicates per treatment, types of negative controls, dependent variables, covariates, and the timing of checkpoints for the experimental design. We also recommend specific preliminary experiments to determine effective methods for parasite quantification, transmission, and preservation. Although these methodological considerations are technical, they also often have conceptual implications. To this end, we encourage other researchers to design and conduct in vivo evolution experiments with blood-borne parasitic microbes, despite the challenges that the work entails.
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Affiliation(s)
- Ruth Rodríguez‐Pastor
- Jacob Blaustein Center for Scientific Cooperation, The Jacob Blaustein Institutes for Desert ResearchBen‐Gurion University of the NegevMidreshet Ben‐GurionIsrael
| | - Yarden Shafran
- Mitrani Department of Desert Ecology, Swiss Institute for Dryland Environmental and Energy Research, The Jacob Blaustein Institutes for Desert ResearchBen‐Gurion University of the NegevMidreshet Ben‐GurionIsrael
| | - Nadav Knossow
- Mitrani Department of Desert Ecology, Swiss Institute for Dryland Environmental and Energy Research, The Jacob Blaustein Institutes for Desert ResearchBen‐Gurion University of the NegevMidreshet Ben‐GurionIsrael
| | - Ricardo Gutiérrez
- Koret School of Veterinary Medicine, Faculty of Agricultural, Nutritional and Environmental SciencesThe Hebrew University of JerusalemRehovotIsrael
| | - Shimon Harrus
- Koret School of Veterinary Medicine, Faculty of Agricultural, Nutritional and Environmental SciencesThe Hebrew University of JerusalemRehovotIsrael
| | - Luis Zaman
- Department of Ecology and Evolutionary Biology, The Center for the Study of Complex Systems (CSCS)University of MichiganAnn ArborMichiganUSA
| | - Richard E. Lenski
- Department of Microbiology and Molecular GeneticsMichigan State UniversityEast LansingMichiganUSA
| | - Jeffrey E. Barrick
- Department of Molecular BiosciencesThe University of Texas AustinAustinTexasUSA
| | - Hadas Hawlena
- Mitrani Department of Desert Ecology, Swiss Institute for Dryland Environmental and Energy Research, The Jacob Blaustein Institutes for Desert ResearchBen‐Gurion University of the NegevMidreshet Ben‐GurionIsrael
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3
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Genestet C, Refrégier G, Hodille E, Zein-Eddine R, Le Meur A, Hak F, Barbry A, Westeel E, Berland JL, Engelmann A, Verdier I, Lina G, Ader F, Dray S, Jacob L, Massol F, Venner S, Dumitrescu O. Mycobacterium tuberculosis genetic features associated with pulmonary tuberculosis severity. Int J Infect Dis 2022; 125:74-83. [PMID: 36273524 DOI: 10.1016/j.ijid.2022.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Mycobacterium tuberculosis (Mtb) infections result in a wide spectrum of clinical presentations but without proven Mtb genetic determinants. Herein, we hypothesized that the genetic features of Mtb clinical isolates, such as specific polymorphisms or microdiversity, may be linked to tuberculosis (TB) severity. METHODS A total of 234 patients with pulmonary TB (including 193 drug-susceptible and 14 monoresistant cases diagnosed between 2017 and 2020 and 27 multidrug-resistant cases diagnosed between 2010 and 2020) were stratified according to TB disease severity, and Mtb genetic features were explored using whole genome sequencing, including heterologous single-nucleotide polymorphism (SNP), calling to explore microdiversity. Finally, we performed a structural equation modeling analysis to relate TB severity to Mtb genetic features. RESULTS The clinical isolates from patients with mild TB carried mutations in genes associated with host-pathogen interaction, whereas those from patients with moderate/severe TB carried mutations associated with regulatory mechanisms. Genome-wide association study identified an SNP in the promoter of the gene coding for the virulence regulator espR, statistically associated with moderate/severe disease. Structural equation modeling and model comparisons indicated that TB severity was associated with the detection of Mtb microdiversity within clinical isolates and to the espR SNP. CONCLUSION Taken together, these results provide a new insight to better understand TB pathophysiology and could provide a new prognosis tool for pulmonary TB severity.
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Affiliation(s)
- Charlotte Genestet
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Rhône-Alpes, Lyon, France.
| | - Guislaine Refrégier
- Université Paris-Saclay, CNRS, AgroParisTech, Ecologie Systématique et Evolution, Île-de-France, Orsay, France.; Institute for Integrative Biology of the Cell (I2BC), CEA, CNRS, Université Paris Sud, Université Paris-Saclay, Île-de-France, Gif-sur-Yvette, France
| | - Elisabeth Hodille
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Rhône-Alpes, Lyon, France
| | - Rima Zein-Eddine
- Université Paris-Saclay, CNRS, AgroParisTech, Ecologie Systématique et Evolution, Île-de-France, Orsay, France.; Institute for Integrative Biology of the Cell (I2BC), CEA, CNRS, Université Paris Sud, Université Paris-Saclay, Île-de-France, Gif-sur-Yvette, France; Laboratory of Optics and Biosciences, CNRS-INSERM-Ecole Polytechnique, Île-de-France, Palaiseau, France
| | - Adrien Le Meur
- Université Paris-Saclay, CNRS, AgroParisTech, Ecologie Systématique et Evolution, Île-de-France, Orsay, France.; Institute for Integrative Biology of the Cell (I2BC), CEA, CNRS, Université Paris Sud, Université Paris-Saclay, Île-de-France, Gif-sur-Yvette, France
| | - Fiona Hak
- Université Paris-Saclay, CNRS, AgroParisTech, Ecologie Systématique et Evolution, Île-de-France, Orsay, France.; Institute for Integrative Biology of the Cell (I2BC), CEA, CNRS, Université Paris Sud, Université Paris-Saclay, Île-de-France, Gif-sur-Yvette, France
| | - Alexia Barbry
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Rhône-Alpes, Lyon, France
| | - Emilie Westeel
- Fondation Mérieux, Emerging Pathogens Laboratory, Rhône-Alpes, Lyon, France
| | - Jean-Luc Berland
- Fondation Mérieux, Emerging Pathogens Laboratory, Rhône-Alpes, Lyon, France
| | - Astrid Engelmann
- Centre Hospitalier Fleyriat, Rhône-Alpes, Bourg-en-Bresse, France
| | - Isabelle Verdier
- Centre Hospitalier Fleyriat, Rhône-Alpes, Bourg-en-Bresse, France
| | - Gérard Lina
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Rhône-Alpes, Lyon, France; Université Lyon 1, Facultés de Médecine et de Pharmacie de Lyon, Rhône-Alpes, Lyon, France
| | - Florence Ader
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Service des Maladies infectieuses et tropicales, Rhône-Alpes, Lyon, France
| | - Stéphane Dray
- Biometrics and Evolutionary Biology Laboratory, CNRS UMR 5558, Université Lyon 1, Rhône-Alpes, Villeurbanne, France
| | - Laurent Jacob
- Biometrics and Evolutionary Biology Laboratory, CNRS UMR 5558, Université Lyon 1, Rhône-Alpes, Villeurbanne, France
| | - François Massol
- UMR 8198 Evo-Eco-Paleo, SPICI Group, University of Lille, Hauts-de-France, Lille, France; CNRS, CHU Lille, Institut Pasteur de Lille, U1019-UMR 9017-CIIL-Center for Infection and Immunity of Lille, University of Lille, Hauts-de-France, Lille, France
| | - Samuel Venner
- Biometrics and Evolutionary Biology Laboratory, CNRS UMR 5558, Université Lyon 1, Rhône-Alpes, Villeurbanne, France
| | - Oana Dumitrescu
- CIRI - Centre International de Recherche en Infectiologie, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon-1, Rhône-Alpes, Lyon, France; Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Rhône-Alpes, Lyon, France; Université Lyon 1, Facultés de Médecine et de Pharmacie de Lyon, Rhône-Alpes, Lyon, France
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Jones RM, Adams KN, Eldesouky HE, Sherman DR. The evolving biology of Mycobacterium tuberculosis drug resistance. Front Cell Infect Microbiol 2022; 12:1027394. [PMID: 36275024 PMCID: PMC9579286 DOI: 10.3389/fcimb.2022.1027394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/20/2022] [Indexed: 01/13/2023] Open
Abstract
Tuberculosis, caused by Mycobacterium tuberculosis (Mtb) is an ancient disease that has remained a leading cause of infectious death. Mtb has evolved drug resistance to every antibiotic regimen ever introduced, greatly complicating treatment, lowering rates of cure and menacing TB control in parts of the world. As technology has advanced, our understanding of antimicrobial resistance has improved, and our models of the phenomenon have evolved. In this review, we focus on recent research progress that supports an updated model for the evolution of drug resistance in Mtb. We highlight the contribution of drug tolerance on the path to resistance, and the influence of heterogeneity on tolerance. Resistance is likely to remain an issue for as long as drugs are needed to treat TB. However, with technology driving new insights and careful management of newly developed resources, antimicrobial resistance need not continue to threaten global progress against TB, as it has done for decades.
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Affiliation(s)
| | | | | | - David R. Sherman
- Department of Microbiology, University of Washington, Seattle, WA, United States
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Bahuaud O, Genestet C, Hoffmann J, Dumitrescu O, Ader F. Opti-4TB: A protocol for a prospective cohort study evaluating the performance of new biomarkers for active tuberculosis outcome prediction. Front Med (Lausanne) 2022; 9:998972. [PMID: 36186786 PMCID: PMC9515406 DOI: 10.3389/fmed.2022.998972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Tuberculosis (TB) treatment requires the combination of multiple anti-TB drugs during 6 months or more depending on strain drug susceptibility profile. Optimizing the monitoring of anti-TB therapy efficacy is required to provide adequate care and prevent drug resistance emergence. Moreover, accurate monitoring tools are needed for the development of strategies aiming at reducing treatment duration. Opti-4TB is a “proof of concept” study aiming at developing a blood-based monitoring of TB outcome by deciphering host immune signatures associated with latency or disease activity through the combination of “omic” methods. The primary objective is to assess the performances of new biomarkers for TB outcome prediction and to determine specific profiles associated with the outcome of treated TB patients. Methods and analysis Opti-4TB is a prospective, single center study including adult patients hospitalized for pulmonary TB. A workflow will be set up to study the immune status of 40 TB patients and 20 controls with latent TB infection. Blood samples will be collected at four timepoints: before treatment initiation (V1), at day 15 (V2), at 2 months (V3) and at 6 months (V4). Mtb-specific immune responses will be assessed at each timepoint with three different assays: (1) A whole blood transcriptomic signature assessing the “RISK-6” score; (2) A proteomic signature based on 27 cytokines and chemokines measured in plasma; (3) An immunophenotypic monitoring of circulating T-cell subpopulations using spectral flow cytometry. This in depth characterization of Mtb-specific immune response throughout the treatment, correlated with clinical outcomes, will lay the basis for the elaboration of the most basic and universal stage-specific immune signatures associated with latency, active disease and cure. Ethics and dissemination Ethical approval has been obtained from the institutional review board (n°69HCL18_0757). Results will be communicated at scientific meetings and submitted for publication in peer-reviewed journals. Trial registration number NCT04271397.
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Affiliation(s)
- Olivier Bahuaud
- Département des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon I, CNRS, UMR5308, École Normale Supérieure de Lyon, Lyon, France
| | - Charlotte Genestet
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon I, CNRS, UMR5308, École Normale Supérieure de Lyon, Lyon, France
- Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Lyon, France
| | | | - Oana Dumitrescu
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon I, CNRS, UMR5308, École Normale Supérieure de Lyon, Lyon, France
- Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de bactériologie, Lyon, France
- Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Ader
- Département des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon I, CNRS, UMR5308, École Normale Supérieure de Lyon, Lyon, France
- Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France
- *Correspondence: Florence Ader
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Chedid C, Andrieu T, Kokhreidze E, Tukvadze N, Biswas S, Ather MF, Uddin MKM, Banu S, De Maio F, Delogu G, Endtz H, Goletti D, Vocanson M, Dumitrescu O, Hoffmann J, Ader F. In-Depth Immunophenotyping With Mass Cytometry During TB Treatment Reveals New T-Cell Subsets Associated With Culture Conversion. Front Immunol 2022; 13:853572. [PMID: 35392094 PMCID: PMC8980213 DOI: 10.3389/fimmu.2022.853572] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022] Open
Abstract
Tuberculosis (TB) is a difficult-to-treat infection because of multidrug regimen requirements based on drug susceptibility profiles and treatment observance issues. TB cure is defined by mycobacterial sterilization, technically complex to systematically assess. We hypothesized that microbiological outcome was associated with stage-specific immune changes in peripheral whole blood during TB treatment. The T-cell phenotypes of treated TB patients were prospectively characterized in a blinded fashion using mass cytometry after Mycobacterium tuberculosis (Mtb) antigen stimulation with QuantiFERON-TB Gold Plus, and then correlated to sputum culture status. At two months of treatment, cytotoxic and terminally differentiated CD8+ T-cells were under-represented and naïve CD4+ T-cells were over-represented in positive- versus negative-sputum culture patients, regardless of Mtb drug susceptibility. At treatment completion, a T-cell immune shift towards differentiated subpopulations was associated with TB cure. Overall, we identified specific T-cell profiles associated with slow sputum converters, which brings new insights in TB prognostic biomarker research designed for clinical application.
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Affiliation(s)
- Carole Chedid
- Centre International de Recherche en Infectiologie, Legionella Pathogenesis Group, INSERM U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, École Normale Supérieure de Lyon, Lyon, France.,Medical and Scientific Department, Fondation Mérieux, Lyon, France.,Département de Biologie, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Thibault Andrieu
- Cytometry Core Facility, Centre de Recherche en Cancérologie de Lyon, Université Claude Bernard Lyon 1, Inserm 1052, CNRS 5286, Centre Léon Bérard, Lyon, France
| | - Eka Kokhreidze
- National Center for Tuberculosis and Lung Diseases (NCTBLD), Tbilisi, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases (NCTBLD), Tbilisi, Georgia
| | - Samanta Biswas
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Fahim Ather
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Khaja Mafij Uddin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayera Banu
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Flavio De Maio
- Dipartimento di Scienze biotecnologiche di base, cliniche intensivologiche e perioperatorie - Sezione di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Delogu
- Dipartimento di Scienze biotecnologiche di base, cliniche intensivologiche e perioperatorie - Sezione di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hubert Endtz
- Medical and Scientific Department, Fondation Mérieux, Lyon, France
| | - Delia Goletti
- Department of Epidemiology and Preclinical Research, "L. Spallanzani" National Institute for Infectious Diseases-IRCCS, Rome, Italy
| | - Marc Vocanson
- Centre International de Recherche en Infectiologie, Legionella Pathogenesis Group, INSERM U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, École Normale Supérieure de Lyon, Lyon, France
| | - Oana Dumitrescu
- Centre International de Recherche en Infectiologie, Legionella Pathogenesis Group, INSERM U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, École Normale Supérieure de Lyon, Lyon, France.,Hospices Civils de Lyon, Institut des Agents Infectieux, Laboratoire de Bactériologie, Lyon, France.,Université Lyon 1, Facultés de Médecine et de Pharmacie de Lyon, Lyon, France
| | - Jonathan Hoffmann
- Centre International de Recherche en Infectiologie, Legionella Pathogenesis Group, INSERM U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, École Normale Supérieure de Lyon, Lyon, France.,Medical and Scientific Department, Fondation Mérieux, Lyon, France
| | - Florence Ader
- Centre International de Recherche en Infectiologie, Legionella Pathogenesis Group, INSERM U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, École Normale Supérieure de Lyon, Lyon, France.,Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Département des Maladies Infectieuses et Tropicales, Lyon, France
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