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Bassetti M, Cascio A, De Rosa FG, Meschiari M, Parrella R, Petrosillo N, Armuzzi A, Caprioli F, Dentali F, Pani M, Pilotto A, Restelli U, Sanguinetti M. Management of Clostridioides difficile infection: an Italian Delphi consensus. J Antimicrob Chemother 2024; 79:2103-2118. [PMID: 39008427 PMCID: PMC11368432 DOI: 10.1093/jac/dkae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI), a leading cause of nosocomial deaths, is a microbiota-mediated disease. As such, the use of broader spectrum antibiotics, such as vancomycin and metronidazole, can prime the gastrointestinal tract to become more prone to CDI recurrences. Fidaxomicin, a narrow-spectrum antibiotic, has been demonstrated to be superior in preventing recurrence and in preserving the intestinal microbiota; however, widespread employment worldwide has been hindered due to high acquisition costs. OBJECTIVES To integrate the currently available guidelines on the management of CDI and to shed light on the timeliest employment of fidaxomicin. METHODS An expert panel was gathered to obtain consensus using Delphi methodology on a series of statements regarding the management of CDI and on appropriate antibiotic use. RESULTS Consensus was reached on 21 of the 25 statements addressing the management of CDI. CONCLUSIONS Delphi methodology was used to achieve consensus on the management of CDI, on the identification of patients at risk of recurrences or severe infection, and on the most appropriate use of fidaxomicin, with the final aim of fostering clinical practice application of treatment algorithms proposed by previous guidelines, in absolute synergy. It could be an important tool to promote more appropriate and cost-effective CDI treatments in European settings with limited resources, like Italy.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Antonio Cascio
- Department PROMISE—Infectious and Tropical Diseases Unit, AOU Policlinico “P. Giaccone”, University of Palermo, 90127 Palermo, Italy
| | | | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena, Policlinico di Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Roberto Parrella
- Unit of Respiratory Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, 80131 Naples, Italy
| | - Nicola Petrosillo
- Infection Prevention and Control Service, Fondazione Policlinico Universitario Campus Bio-Medico, 00127 Rome, Italy
| | - Alessandro Armuzzi
- IBD Unit, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20133 Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Francesco Dentali
- Division of Internal Medicine, Medical Center, Ospedale di Circolo & Fondazione Macchi, ASST Sette Laghi, 21100 Varese, Italy
- Department of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Marcello Pani
- Hospital Pharmacy, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alberto Pilotto
- Department of Interdisciplinary Medicine, ‘Aldo Moro’ University of Bari, 70121 Bari, Italy
- Geriatrics Unit, Department of Geriatric Care, Neurology and Rehabilitation, Galliera Hospitals, 16128 Genova, Italy
| | | | - Maurizio Sanguinetti
- Department of Laboratory and Infectious Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
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Granata G. Introduction to the Special Issue on Clostridioides difficile Infection, Second Edition. Antibiotics (Basel) 2024; 13:607. [PMID: 39061289 PMCID: PMC11274262 DOI: 10.3390/antibiotics13070607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Clostridioides difficile (CD) is a Gram-positive, anaerobic bacterium that is one of the most common causes of infective diarrhoea worldwide [...].
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Affiliation(s)
- Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, 00149 Rome, Italy
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Granata G, Barbut F, Petrosillo N. Editorial: Clostridioides difficile infection. Front Med (Lausanne) 2024; 11:1372813. [PMID: 38468753 PMCID: PMC10925766 DOI: 10.3389/fmed.2024.1372813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 03/13/2024] Open
Affiliation(s)
- Guido Granata
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases “L. Spallanzani”, IRCCS, Rome, Italy
| | - Frédéric Barbut
- National Reference Laboratory for Clostridioides Difficile, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicola Petrosillo
- Infection Prevention and Control Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Karp J, Edman-Wallér J, Toepfer M, Jacobsson G. Risk factors for recurrent healthcare-facility associated Clostridioides difficile infection in a Swedish setting. Anaerobe 2023; 81:102738. [PMID: 37217115 DOI: 10.1016/j.anaerobe.2023.102738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE The objectives were to determine the risk factors for recurrent healthcare facility-associated Clostridioides difficile infection (HCF-CDI) in a high CDI incidence, low antibiotic use setting and to determine if length of cefotaxime exposure is a risk factor for recurrent HCF-CDI. METHODS The risk factors for recurrent HCF-CDI were evaluated with a retrospective nested case control study based on chart reading. The risk factors were evaluated univariately and multivariately. Length of risk antibiotic exposure was evaluated further in a subanalysis. RESULTS Risk factors for recurrent HCF-CDI were renal insufficiency (25.4% of cases compared to 15.4% of controls p = 0.006) and metronidazole treatment of initial CDI episode (88.4% compared to 71.7% p = 0.01). Exposure to cefotaxime and risk for recurrent CDI showed a dose-dependent relationship (linear by linear p = 0.028). CONCLUSIONS Renal insufficiency and metronidazole treatment were independent risk factors for recurrent HCF-CDI in our setting. The relationship between cefotaxime exposure and risk for recurrent HCF-CDI, dose-dependent, could be evaluated further in a setting with high cefotaxime use.
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Affiliation(s)
- Johan Karp
- Department of Infectious Diseases, Skaraborg Hospital, Skövde, Sweden, Lövängsvägen, 451 42, Skövde, Sweden; Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, Box 440, 405 30, Göteborg, Sweden.
| | - Jon Edman-Wallér
- Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, Box 440, 405 30, Göteborg, Sweden; Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden, Guldhedsgatan 10 A, 413 46, Göteborg, Sweden.
| | - Michael Toepfer
- Clinical Microbiology, Unilabs AB, Skövde, Sweden, Rådhusgatan 6, 54130, Skövde, Sweden.
| | - Gunnar Jacobsson
- Department of Infectious Diseases, Skaraborg Hospital, Skövde, Sweden, Lövängsvägen, 451 42, Skövde, Sweden; Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, Box 440, 405 30, Göteborg, Sweden.
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Medaglia AA, Mancuso A, Albano C, Zinna G, Pipitò L, Calà C, Immordino R, Rubino R, Bonura S, Canino B, Calamusa G, Colomba C, Almasio PL, Cascio A. Clostridioides difficile Infection in an Italian Tertiary Care University Hospital: A Retrospective Analysis. Antibiotics (Basel) 2023; 12:antibiotics12050837. [PMID: 37237740 DOI: 10.3390/antibiotics12050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a significant cause of morbidity and mortality, mostly in frail patients. Notification is not mandatory in Italy, and data on incidence, risk of death, and recurrence are lacking. The purpose of this study was to determine CDI incidence and risk factors for mortality and recurrence. The "ICD-9 00845" code in hospital-standardized discharged forms (H-SDF) and microbiology datasets were used to retrieve CDI cases at Policlinico Hospital, Palermo between 2013 and 2022. Incidence, ward distribution, recurrence rate, mortality, and coding rate were considered. The risk of death and recurrence was predicted through multivariable analysis. There were 275 CDIs, 75% hospital-acquired, the median time between admission and diagnosis was 13 days, and the median stay was 21 days. Incidence increased from 0.3 to 5.6% (an 18.7-fold increase) throughout the decade. Only 48.1% of cases were coded in H-SDF. The rate of severe/severe-complicated cases increased 1.9 times. Fidaxomicin was used in 17.1% and 24.7% of cases overall and since 2019. Overall and attributable mortalities were 11.3% and 4.7%, respectively. Median time between diagnosis and death was 11 days, and recurrence rate was 4%. Bezlotoxumab was administered in 64% of recurrences. Multivariable analysis revealed that only hemodialysis was associated with mortality. No statistically significant association in predicting recurrence risk emerged. We advocate for CDI notification to become mandatory and recommend coding CDI diagnosis in H-SDF to aid in infection rate monitoring. Maximum attention should be paid to preventing people on hemodialysis from getting CDI.
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Affiliation(s)
- Alice Annalisa Medaglia
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Alessandro Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Chiara Albano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Giuseppe Zinna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Luca Pipitò
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Cinzia Calà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
- Microbiology and Virology Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Rita Immordino
- Microbiology and Virology Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Raffaella Rubino
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Silvia Bonura
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Baldassare Canino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Giuseppe Calamusa
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Claudia Colomba
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Pier Luigi Almasio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Antonio Cascio
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
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Granata G, Schiavone F, Pipitone G. Bezlotoxumab in Patients with a Primary Clostridioides difficile Infection: A Literature Review. Antibiotics (Basel) 2022; 11:1495. [PMID: 36358149 PMCID: PMC9687042 DOI: 10.3390/antibiotics11111495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Nowadays, one of the main issues in the management of Clostridioides difficile infection (CDI) is the high rate of recurrences (rCDI), causing increased mortality and higher health care costs. OBJECTIVES To assess the available evidence on the use of bezlotoxumab for the prevention of rCDI during a first CDI episode. METHODS Published articles on bezlotoxumab during a primary CDI episode were identified through computerized literature searches with the search terms [(bezlotoxumab) AND (CDI) OR (Clostridioides difficile infection)] using PubMed and by reviewing the references of retrieved articles. PubMed was searched until 31 August 2022. RESULTS Eighty-eight studies were identified as published from December 2014 to June 2022. Five studies were included in this study, one was a phase III clinical trial and four were sub-analyses or extensions of the previous phase III clinical trial. In the phase III clinical trial, the subgroup analysis on the included primary CDI patients showed that 13.5% of patients receiving bezlotoxumab had an rCDI, whilst 20.9% of patients in the placebo group had an rCDI at the twelve weeks follow-up (absolute difference: -7.4). CONCLUSIONS Bezlotoxumab administration during the standard of care antibiotic therapy is effective and safe in reducing the rate of rCDI. Despite its high cost, evidence suggests considering bezlotoxumab in patients with a primary CDI episode. Further studies are needed to assess the benefit in specific subgroups of primary CDI patients and to define the risk factors to guide bezlotoxumab use.
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Affiliation(s)
- Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, 00149 Rome, Italy
| | - Francesco Schiavone
- Divers and Raiders Group Command “Teseo Tesei” COMSUBIN, Medical Service, Italian Navy, 19025 Portovenere, Italy
| | - Giuseppe Pipitone
- Infectious Disease Unit, ARNAS Civico-Di Cristina, Piazza Leotta, 5, 90100 Palermo, Italy
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Clostridioides difficile Infection: A Never-Ending Challenge. J Clin Med 2022; 11:jcm11144115. [PMID: 35887876 PMCID: PMC9317075 DOI: 10.3390/jcm11144115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 01/27/2023] Open
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Oral Vancomycin Prophylaxis for Primary and Secondary Prevention of Clostridioides difficile Infection in Patients Treated with Systemic Antibiotic Therapy: A Systematic Review, Meta-Analysis and Trial Sequential Analysis. Antibiotics (Basel) 2022; 11:antibiotics11020183. [PMID: 35203786 PMCID: PMC8868369 DOI: 10.3390/antibiotics11020183] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality as well as high propensity of recurrence. Systemic antibiotic therapy (SAT) represents the top inciting factor of CDI, both primary and recurrent (rCDI). Among the many strategies aimed to prevent CDI in high-risk subjects undergoing SAT, oral vancomycin prophylaxis (OVP) appears promising under a cost-effectiveness perspective. Methods: A systematic review with meta-analysis and trial sequential analysis (TSA) of studies assessing the efficacy and the safety of OVP to prevent primary CDI and rCDI in persons undergoing SAT was carried out. PubMed and EMBASE were searched until 30 September 2021. The protocol was pre-registered on PROSPERO (CRD42019145543). Results: Eleven studies met the inclusion criteria, only one being a randomized controlled trial (RCT). Overall, 929 subjects received OVP and 2011 represented the comparator group (no active prophylaxis). OVP exerted a strong protective effect for CDI occurrence: odds ratio 0.14, 95% confidence interval 0.04–0.38. Moderate heterogeneity was observed: I2 54%. This effect was confirmed throughout several subgroup analyses, including prevention of primary CDI versus rCDI. TSA results pointed at the conclusive nature of the evidence. Results were robust to a variety of sensitivity and quantitative bias analyses, although the underlying evidence was deemed as low quality. No differences between the two groups were highlighted regarding the onset of vancomycin-resistant Enterococcus infections. Conclusions: OVP appears to be an efficacious option for prevention of CDI in high-risk subjects undergoing SAT. Nevertheless, additional data from RCTs are needed to establish OVP as good clinical practice and define optimal dosage and duration.
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Introduction to the Special Issue on Clostridioides difficile. Antibiotics (Basel) 2021; 10:antibiotics10101233. [PMID: 34680813 PMCID: PMC8532899 DOI: 10.3390/antibiotics10101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
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Medaglia AA, Buffa S, Gioè C, Bonura S, Rubino R, Iaria C, Colomba C, Cascio A. An emergent infectious disease: Clostridioides difficile infection hospitalizations, 10-year trend in Sicily. Infection 2021; 49:1221-1229. [PMID: 34495497 PMCID: PMC8613107 DOI: 10.1007/s15010-021-01683-w] [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: 06/06/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
Background Clostridioides difficile is the most common cause of healthcare-associated diarrhoea worldwide and C. difficile infection is an emerging infectious disease. In the US, its rates are monitored trough an active surveillance system, but many European Union member states still lack this, and in Italy no epidemiological data on C. difficile infection are available except for a few single-centre data. Aim To provide data on the C. difficile infection incidence in Sicily (the biggest and 5th most populous region of Italy) during a 10-year period. Methods We revised all the regional standardized discharge forms between 2009 and June 2019 using the code ICD-9 00845 of the International Classification of Diseases, Ninth Revision Clinical Modification, which refers to C. difficile infection with or without complications. Results 1139 cases of CDI were identified. 97% were adults with a median age of 73.2 years and a male-to-female ratio of 1:1.4. Female patients were older than males and patients who died were older than patients who did not. The main comorbidities were renal disease, diabetes, pneumonia and hypertension. There were 65 reporting hospitals and 86% of cases were provided by level III and II hospitals. Between 2009 and 2019, the incidence increased 40-fold. 81.5% of cases were reported in Medicine Units, Infectious Diseases Units and long-term care facilities. The mean length of stay was 20 days. Mean case fatality rate was 8.3% over the 10-year period. Conclusion Clostridioides difficile infection is a dramatically increasing condition in Sicily. A high-quality surveillance system and shared diagnostic protocols are needed. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-021-01683-w.
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Affiliation(s)
| | - Sergio Buffa
- Dipartimento per le Attività Sanitarie e Osservatorio Epidemiologico (DASOE), Palermo, Italy
| | - Claudia Gioè
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Silvia Bonura
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Raffaella Rubino
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Chiara Iaria
- Infectious Diseases Unit, ARNAS Civico, Palermo, Italy
| | - Claudia Colomba
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Infectious Diseases Unit, University of Palermo, Palermo, Italy
| | - Antonio Cascio
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy. .,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Infectious Diseases Unit, University of Palermo, Palermo, Italy.
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