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Calderon Toledo C, von Mentzer A, Agramont J, Thorell K, Zhou Y, Szabó M, Colque P, Kuhn I, Gutiérrez-Cortez S, Joffré E. Circulation of enterotoxigenic Escherichia coli (ETEC) isolates expressing CS23 from the environment to clinical settings. mSystems 2023; 8:e0014123. [PMID: 37681982 PMCID: PMC10654058 DOI: 10.1128/msystems.00141-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/27/2023] [Indexed: 09/09/2023] Open
Abstract
IMPORTANCE The importance of clean water cannot be overstated. It is a vital resource for maintaining health and well-being. Unfortunately, water sources contaminated with fecal discharges from animal and human origin due to a lack of wastewater management pose a significant risk to communities, as they can become a means of transmission of pathogenic bacteria like enterotoxigenic E. coli (ETEC). ETEC is frequently found in polluted water in countries with a high prevalence of diarrheal diseases, such as Bolivia. This study provides novel insights into the circulation of ETEC between diarrheal cases and polluted water sources in areas with high rates of diarrheal disease. These findings highlight the Choqueyapu River as a potential reservoir for emerging pathogens carrying antibiotic-resistance genes, making it a crucial area for monitoring and intervention. Furthermore, the results demonstrate the feasibility of a low-cost, high-throughput method for tracking bacterial pathogens in low- and middle-income countries, making it a valuable tool for One Health monitoring efforts.
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Affiliation(s)
- Carla Calderon Toledo
- Unidad de Microbiología Ambiental, Instituto de Biología Molecular y Biotecnología (IBMB), Carrera de Biología, Universidad Mayor de San Andrés, La Paz, Bolivia
| | - Astrid von Mentzer
- Wellcome Sanger Institute, Hinxton, Cambridge, United Kingdom
- Department of Microbiology and Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Jorge Agramont
- Unidad de Microbiología Ambiental, Instituto de Biología Molecular y Biotecnología (IBMB), Carrera de Biología, Universidad Mayor de San Andrés, La Paz, Bolivia
| | - Kaisa Thorell
- Department of Chemistry and Molecular Biology (CMB), University of Gothenburg, Gothenburg, Sweden
| | - Yingshun Zhou
- Department of Pathogen Biology, The public platform of the Pathogen Biology, School of Basic Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Miklós Szabó
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institutet, Stockholm, Sweden
| | - Patricia Colque
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institutet, Stockholm, Sweden
| | - Inger Kuhn
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institutet, Stockholm, Sweden
| | - Sergio Gutiérrez-Cortez
- Unidad de Microbiología Ambiental, Instituto de Biología Molecular y Biotecnología (IBMB), Carrera de Biología, Universidad Mayor de San Andrés, La Paz, Bolivia
| | - Enrique Joffré
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institutet, Stockholm, Sweden
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Enemchukwu CM, Oli AN, Okoye EI, Ujam NT, Osazuwa EO, Emechebe GO, Okeke KN, Ifezulike CC, Ejiofor OS, Okoyeh JN. Winning the War against Multi-Drug Resistant Diarrhoeagenic Bacteria. Microorganisms 2019; 7:microorganisms7070197. [PMID: 31295889 PMCID: PMC6680719 DOI: 10.3390/microorganisms7070197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 01/12/2023] Open
Abstract
Drug-resistant-diarrhoeagenic bacteria are currently emerging healthcare challenge. This study investigated the effects of Vernonia amygdalina, Garcinia kola, tetracycline and metronidazole combinations on such bacteria. Agar well diffusion method was employed to determine the inhibitory effects of the herbal extracts on diarrhoeagenic bacteria while Time-Kill Assay was used to determine bactericidal effects of the extracts against test isolates. Interactions between plant extracts and antibiotics were investigated using Checkerboard assay. Minimum inhibitory concentrations of the extracts against the bacterial isolates ranged between 3.125–50 mg/mL, while those of tetracycline and metronidazole ranged from 30–50 μg/mL. Synergism was observed against B. cereus and S. aureus for metronidazole + aqueous G. kola at all ratios. Generally, the combinations aqueous G. kola + ethanolic G. kola and aqueous G. kola + ethanolic V. amygdalina showed more pronounced synergism against the Staphylococcus aureus than B. cereus isolates with the fractional inhibition concentration (FIC) indices ranging from 0.32–0.95. Synergism of tetracycline + crude extracts and metronidazole combinations were more pronounced on the test isolates and especially on the Gram-negative organisms with FIC indices ranging from 0.41–0.91. Conclusion: The herbal extracts combinations and extracts–antibiotics combinations are synergistic on diarrhoeagenic bacteria at defined combination ratios.
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Affiliation(s)
- Chizoba Mercy Enemchukwu
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Agulu, Nnamdi Azikiwe University, Awka 420108, Nigeria
| | - Angus Nnamdi Oli
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Agulu, Nnamdi Azikiwe University, Awka 420108, Nigeria.
| | - Ebere Innocent Okoye
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Agulu, Nnamdi Azikiwe University, Awka 420108, Nigeria
| | - Nonye Treasure Ujam
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Enugu State University of Science and Technology, Enugu 400102, Nigeria
| | - Emmanuel O Osazuwa
- Department of Pharmaceutical Microbiology, School of Pharmacy, University of Benin, Benin-City 300271 Edo State, Nigeria
| | - George Ogonna Emechebe
- Department of Pediatrics, Chukwuemeka Odumegwu Ojukwu University, Awka 420108, Anambra State, Nigeria
| | - Kenneth Nchekwube Okeke
- Department of Pediatrics, Chukwuemeka Odumegwu Ojukwu University, Awka 420108, Anambra State, Nigeria
| | | | - Obiora Shedrack Ejiofor
- Department of Pediatrics, Chukwuemeka Odumegwu Ojukwu University, Awka 420108, Anambra State, Nigeria
| | - Jude Nnaemeka Okoyeh
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Winston Salem State University, Winston-Salem, NC 27101, USA
- Department of Biology and Clinical Laboratory Science, Division of Arts and Sciences, Neumann University, One Neumann Drive, Aston, PA 19014-1298, USA
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3
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Rodea GE, Montiel-Infante FX, Cruz-Córdova A, Saldaña-Ahuactzi Z, Ochoa SA, Espinosa-Mazariego K, Hernández-Castro R, Xicohtencatl-Cortes J. Tracking Bioluminescent ETEC during In vivo BALB/c Mouse Colonization. Front Cell Infect Microbiol 2017; 7:187. [PMID: 28560186 PMCID: PMC5432549 DOI: 10.3389/fcimb.2017.00187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/28/2017] [Indexed: 12/14/2022] Open
Abstract
Enterotoxigenic Escherichia coli (ETEC) is a leading cause of diarrhea worldwide. Adhesion to the human intestinal tract is crucial for colonization. ETEC adhesive structures have been extensively studied; however, colonization dynamics remain uncharacterized. The aim of this study was to track bioluminescent ETEC during in vivo infection. The promoter region of dnaK was fused with the luc gene, resulting in the pRMkluc vector. E. coli K-12 and ETEC FMU073332 strains were electroporated with pRMkluc. E. coli K-12 pRMkluc was bioluminescent; in contrast, the E. coli K-12 control strain did not emit bioluminescence. The highest light emission was measured at 1.9 OD600 (9 h) and quantified over time. The signal was detected starting at time 0 and up to 12 h. Streptomycin-treated BALB/c mice were orogastrically inoculated with either ETEC FMU073332 pRMkluc or E. coli K-12 pRMkluc (control), and bacterial colonization was determined by measuring bacterial shedding in the feces. ETEC FMU073332 pRMkluc shedding started and stopped after inoculation of the control strain, indicating that mouse intestinal colonization by ETEC FMU073332 pRMkluc lasted longer than colonization by the control. The bioluminescence signal of ETEC FMU073332 pRMkluc was captured starting at the time of inoculation until 12 h after inoculation. The bioluminescent signal emitted by ETEC FMU073332 pRMkluc in the proximal mouse ileum was located, and the control signal was identified in the cecum. The detection of maximal light emission and bioluminescence duration allowed us to follow ETEC during in vivo infection. ETEC showed an enhanced colonization and tropism in the mouse intestine compared with those in the control strain. Here, we report the first study of ETEC colonization in the mouse intestine accompanied by in vivo imaging.
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Affiliation(s)
- Gerardo E Rodea
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico.,Instituto de Fisiología Celular, Universidad Nacional Autónoma de MéxicoCiudad de México, Mexico
| | - Francisco X Montiel-Infante
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
| | - Ariadnna Cruz-Córdova
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
| | - Zeus Saldaña-Ahuactzi
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
| | - Sara A Ochoa
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
| | - Karina Espinosa-Mazariego
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
| | - Rigoberto Hernández-Castro
- Departamento de Ecología de Agentes Patógenos, Hospital General "Dr. Manuel Gea González"Ciudad de México, Mexico
| | - Juan Xicohtencatl-Cortes
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico
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Genome Sequence of Enterotoxigenic Escherichia coli Strain FMU073332. GENOME ANNOUNCEMENTS 2017; 5:5/8/e01600-16. [PMID: 28232434 PMCID: PMC5323613 DOI: 10.1128/genomea.01600-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Enterotoxigenic Escherichia coli (ETEC) is an important cause of bacterial diarrheal illness, affecting practically every population worldwide, and was estimated to cause 120,800 deaths in 2010. Here, we report the genome sequence of ETEC strain FMU073332, isolated from a 25-month-old girl from Tlaltizapán, Morelos, México.
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Kharat VB, Ahmed M, Jiang ZD, Riddle MS, DuPont HL. Colonization Factors in Enterotoxigenic Escherichia coli Strains in Travelers to Mexico, Guatemala, and India Compared with Children in Houston, Texas. Am J Trop Med Hyg 2016; 96:83-87. [PMID: 28077742 DOI: 10.4269/ajtmh.16-0405] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/23/2016] [Indexed: 12/15/2022] Open
Abstract
Enterotoxigenic Escherichia coli (ETEC) can be attributed to around 200 million diarrheal episodes and 380,000 deaths in the developing regions. Travelers' diarrhea occurs in 15-40% of travelers to developing regions with ETEC being the most important etiologic agent. This study aims to describe the distribution of enterotoxins and colonization factor (CF) profiles of ETEC isolates from stool samples of adult travelers acquiring diarrhea in Mexico, Guatemala, and India and a group of children with acute diarrhea in Houston, TX, between 2007 and 2012. The heat-labile/heat-stable (LT/ST) enterotoxins and CFs from 252 patients were determined using polymerase chain reaction assay. Among the 252 ETEC isolates, 15% were LT-only, 58% were ST-only, and 28% produced both LT and ST. The distribution of LT-only (12-15%) and ST-only (55-56%) isolates was similar between Latin American and Indian sites. The most prevalent CF was CS21, expressed in 65% of the isolates followed by CS6 (25%) and CS3 (17%). Among the international travelers, 64% of the ETEC isolates expressed CS21. CS21 was expressed in 46% of isolates from Latin America compared with 96% of isolates from India (P < 0.0001). CS21 was expressed in 85% isolates from Houston children. CS21 was increasingly found in ST-only (P = 0.003) and ST/LT (P = 0.026) ETEC compared with LT-only ETEC. High frequency of finding CS21 among recent isolates of ETEC over a wide geographic distribution warrants additional studies on this CF. Highly conserved CS21 is an important target for potential multivalent ETEC vaccines.
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Affiliation(s)
- Vineetkumar B Kharat
- University of Texas School of Public Health, Center for Infectious Diseases, Houston, Texas
| | - Makhdum Ahmed
- University of Texas School of Public Health, Center for Infectious Diseases, Houston, Texas
| | - Zhi-Dong Jiang
- University of Texas School of Public Health, Center for Infectious Diseases, Houston, Texas.
| | - Mark S Riddle
- Enteric Disease Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Herbert L DuPont
- University of Texas School of Public Health, Center for Infectious Diseases, Houston, Texas.,Baylor College of Medicine, Houston, Texas
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Saldaña-Ahuactzi Z, Rodea GE, Cruz-Córdova A, Rodríguez-Ramírez V, Espinosa-Mazariego K, González-Montalvo MA, Ochoa SA, González-Pedrajo B, Eslava-Campos CA, López-Villegas EO, Hernández-Castro R, Arellano-Galindo J, Patiño-López G, Xicohtencatl-Cortes J. Effects of lng Mutations on LngA Expression, Processing, and CS21 Assembly in Enterotoxigenic Escherichia coli E9034A. Front Microbiol 2016; 7:1201. [PMID: 27536289 PMCID: PMC4971541 DOI: 10.3389/fmicb.2016.01201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/19/2016] [Indexed: 12/22/2022] Open
Abstract
Enterotoxigenic Escherichia coli (ETEC) is a major cause of morbidity in children under 5 years of age in low- and middle-income countries and a leading cause of traveler's diarrhea worldwide. The ability of ETEC to colonize the intestinal epithelium is mediated by fimbrial adhesins, such as CS21 (Longus). This adhesin is a type IVb pilus involved in adherence to intestinal cells in vitro and bacterial self-aggregation. Fourteen open reading frames have been proposed to be involved in CS21 assembly, hitherto only the lngA and lngB genes, coding for the major (LngA) and minor (LngB) structural subunit, have been characterized. In this study, we investigated the role of the LngA, LngB, LngC, LngD, LngH, and LngP proteins in the assembly of CS21 in ETEC strain E9034A. The deletion of the lngA, lngB, lngC, lngD, lngH, or lngP genes, abolished CS21 assembly in ETEC strain E9034A and the adherence to HT-29 cells was reduced 90%, compared to wild-type strain. Subcellular localization prediction of CS21 proteins was similar to other well-known type IV pili homologs. We showed that LngP is the prepilin peptidase of LngA, and that ETEC strain E9034A has another peptidase capable of processing LngA, although with less efficiency. Additionally, we present immuno-electron microscopy images to show that the LngB protein could be localized at the tip of CS21. In conclusion, our results demonstrate that the LngA, LngB, LngC, LngD, LngH, and LngP proteins are essential for CS21 assembly, as well as for bacterial aggregation and adherence to HT-29 cells.
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Affiliation(s)
- Zeus Saldaña-Ahuactzi
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico; Instituto de Fisiología Celular at the Universidad Nacional Autónoma de MéxicoCiudad de México, Mexico
| | - Gerardo E Rodea
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico GómezCiudad de México, Mexico; Instituto de Fisiología Celular at the Universidad Nacional Autónoma de MéxicoCiudad de México, Mexico
| | - Ariadnna Cruz-Córdova
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Viridiana Rodríguez-Ramírez
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Karina Espinosa-Mazariego
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Martín A González-Montalvo
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Sara A Ochoa
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Bertha González-Pedrajo
- Departamento de Genética Molecular, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México Ciudad de México, Mexico
| | - Carlos A Eslava-Campos
- Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional Autónoma de México Ciudad de México, Mexico
| | - Edgar O López-Villegas
- Laboratorio Central de Microscopía, Departamento de Investigación-SEPI, Instituto Politecnico Nacional Ciudad de México, Mexico
| | - Rigoberto Hernández-Castro
- Departamento de Ecología de Agentes Patógenos, Hospital General "Dr. Manuel Gea González" Ciudad de México, Mexico
| | - José Arellano-Galindo
- Departamento de Infectología, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Genaro Patiño-López
- Laboratorio de Investigación en Inmunología y Proteómica, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
| | - Juan Xicohtencatl-Cortes
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez Ciudad de México, Mexico
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7
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Zhang C, Iqbal J, Gómez-Duarte OG. Murine immunization with CS21 pili or LngA major subunit of enterotoxigenic Escherichia coli (ETEC) elicits systemic and mucosal immune responses and inhibits ETEC gut colonization. Vet Microbiol 2016; 202:90-100. [PMID: 26878971 DOI: 10.1016/j.vetmic.2016.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/24/2016] [Accepted: 02/04/2016] [Indexed: 02/07/2023]
Abstract
CS21 pili of enterotoxigenic Escherichia coli (ETEC) is one of the most prevalent ETEC colonization factors. CS21 major subunit, LngA, mediates ETEC adherence to intestinal cells, and contributes to ETEC pathogenesis in a neonatal mouse infection model. The objectives of this work were to evaluate LngA major subunit purified protein and CS21 purified pili on immunogenicity and protection against ETEC colonization of mice intestine. Recombinant LngA purified protein or purified CS21 pili from E9034A ETEC strain were evaluated for immunogenicity after immunization of C57BL/6 mice. Specific anti-LngA antibodies were detected from mice serum, feces, and intestine fluid samples by ELISA assays. Protection against gut colonization was evaluated on immunized mice orally challenged with wild type E9034A ETEC strain and by subsequent quantification of bacterial colony forming units (CFU) recovered from feces. Recombinant LngA protein and CS21 pili induced specific humoral and mucosal anti-LngA antibodies in the mouse model. CS21 combined with CT delivered intranasally as well as LngA combined with incomplete Freund adjuvant delivered intraperitoneally inhibited ETEC gut colonization in a mouse model. In conclusion, both LngA purified protein and CS21 pili from ETEC are highly immunogenic and may inhibit ETEC intestinal shedding. Our data on immunogenicity and immunoprotection indicates that CS21 is a suitable vaccine candidate for a future multivalent vaccine against ETEC diarrhea.
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Affiliation(s)
- Chengxian Zhang
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Junaid Iqbal
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Oscar G Gómez-Duarte
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Yang WE, Suchindran S, Nicholson BP, McClain MT, Burke T, Ginsburg GS, Harro CD, Chakraborty S, Sack DA, Woods CW, Tsalik EL. Transcriptomic Analysis of the Host Response and Innate Resilience to Enterotoxigenic Escherichia coli Infection in Humans. J Infect Dis 2016; 213:1495-504. [PMID: 26787651 DOI: 10.1093/infdis/jiv593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/27/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Enterotoxigenic Escherichia coli (ETEC) is a globally prevalent cause of diarrhea. Though usually self-limited, it can be severe and debilitating. Little is known about the host transcriptional response to infection. We report the first gene expression analysis of the human host response to experimental challenge with ETEC. METHODS We challenged 30 healthy adults with an unattenuated ETEC strain, and collected serial blood samples shortly after inoculation and daily for 8 days. We performed gene expression analysis on whole peripheral blood RNA samples from subjects in whom severe symptoms developed (n = 6) and a subset of those who remained asymptomatic (n = 6) despite shedding. RESULTS Compared with baseline, symptomatic subjects demonstrated significantly different expression of 406 genes highlighting increased immune response and decreased protein synthesis. Compared with asymptomatic subjects, symptomatic subjects differentially expressed 254 genes primarily associated with immune response. This comparison also revealed 29 genes differentially expressed between groups at baseline, suggesting innate resilience to infection. Drug repositioning analysis identified several drug classes with potential utility in augmenting immune response or mitigating symptoms. CONCLUSIONS There are statistically significant and biologically plausible differences in host gene expression induced by ETEC infection. Differential baseline expression of some genes may indicate resilience to infection.
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Affiliation(s)
- William E Yang
- Duke University School of Medicine, Department of Medicine, Duke University Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University
| | - Sunil Suchindran
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University
| | - Bradly P Nicholson
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University Internal Medicine Service, Durham VA Medical Center, Duke University Medical Center, North Carolina
| | - Micah T McClain
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University Internal Medicine Service, Durham VA Medical Center, Duke University Medical Center, North Carolina Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, North Carolina
| | - Thomas Burke
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University
| | - Geoffrey S Ginsburg
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University
| | - Clayton D Harro
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Subhra Chakraborty
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Christopher W Woods
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University Internal Medicine Service, Durham VA Medical Center, Duke University Medical Center, North Carolina Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, North Carolina
| | - Ephraim L Tsalik
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, North Carolina Emergency Medicine Service, Durham VA Medical Center, North Carolina
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