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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [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: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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Caciagli V, Coloretti I, Talamonti M, Farinelli C, Gatto I, Biagioni E, Sarti M, Franceschini E, Meschiari M, Mussini C, Tonelli R, Clini E, Girardis M, Busani S. Association between Pulmonary Aspergillosis and Cytomegalovirus Reactivation in Critically Ill COVID-19 Patients: A Prospective Observational Cohort Study. Viruses 2023; 15:2260. [PMID: 38005936 PMCID: PMC10675747 DOI: 10.3390/v15112260] [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: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
COVID-19-associated invasive pulmonary aspergillosis (CAPA) is common and is associated with poor outcomes in critically ill patients. This prospective observational study aimed to explore the association between CAPA development and the incidence and prognosis of cytomegalovirus (CMV) reactivation in critically ill COVID-19 patients. We included all consecutive critically ill adult patients with confirmed COVID-19 infection who were admitted to three COVID-19 intensive care units (ICUs) in an Italian hospital from 25 February 2020 to 8 May 2022. A standardized procedure was employed for early detection of CAPA. Risk factors associated with CAPA and CMV reactivation and the association between CMV recurrence and mortality were estimated using adjusted Cox proportional hazard regression models. CAPA occurred in 96 patients (16.6%) of the 579 patients analyzed. Among the CAPA population, 40 (41.7%) patients developed CMV blood reactivation with a median time of 18 days (IQR 7-27). The CAPA+CMV group did not exhibit a significantly higher 90-day mortality rate (62.5% vs. 48.2%) than the CAPA alone group (p = 0.166). The CAPA+CMV group had a longer ICU stay, fewer ventilation-free days, and a higher rate of secondary bacterial infections than the control group of CAPA alone. In the CAPA population, prior immunosuppression was the only independent risk factor for CMV reactivation (HR 2.33, 95% C.I. 1.21-4.48, p = 0.011). In critically ill COVID-19 patients, CMV reactivation is common in those with a previous CAPA diagnosis. Basal immunosuppression before COVID-19 appeared to be the primary independent variable affecting CMV reactivation in patients with CAPA. Furthermore, the association of CAPA+CMV versus CAPA alone appears to impact ICU length of stay and secondary bacterial infections but not mortality.
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Affiliation(s)
- Valeria Caciagli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Marta Talamonti
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Carlotta Farinelli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Ilenia Gatto
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Emanuela Biagioni
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Mario Sarti
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Marianna Meschiari
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Cristina Mussini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Roberto Tonelli
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
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Wulff SM, Perch M, Helweg-Larsen J, Bredahl P, Arendrup MC, Lundgren J, Helleberg M, Crone CG. Associations between invasive aspergillosis and cytomegalovirus in lung transplant recipients: a nationwide cohort study. APMIS 2023; 131:574-583. [PMID: 37022293 DOI: 10.1111/apm.13317] [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: 03/28/2023] [Accepted: 04/02/2023] [Indexed: 04/07/2023]
Abstract
Cytomegalovirus (CMV) and invasive aspergillosis (IA) cause morbidity among lung transplant recipients (LTXr). Early diagnosis and treatment could improve outcomes. We examined rates of CMV after IA and vice versa to assess whether screening for one infection is warranted after detecting the other. All Danish LTXr, 2010-2019, were followed for IA and CMV for 2 years after transplantation. IA was defined using ISHLT criteria. Adjusted incidence rate ratios (aIRR) were estimated by Poisson regression adjusted for time after transplantation. We included 295 LTXr, among whom CMV and IA were diagnosed in 128 (43%) and 48 (16%). The risk of CMV was high the first 3 months after IA, IR 98/100 person-years of follow-up (95% CI 47-206). The risk of IA was significantly increased in the first 3 months after CMV, aIRR 2.91 (95% CI 1.32-6.44). Numbers needed to screen to diagnose one case of CMV after IA, and one case of IA after CMV was approximately seven and eight, respectively. Systematic screening for CMV following diagnosis of IA, and vice versa, may improve timeliness of diagnosis and outcomes for LTXr.
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Affiliation(s)
- Signe Marie Wulff
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Pia Bredahl
- Department of Thoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maiken Cavling Arendrup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Cornelia Geisler Crone
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Silva Junior HT, Tokat Y, Cai J, Singh I, Sandhu A, Demuth D, Kim J. Epidemiology, management, and burden of cytomegalovirus in solid organ transplant recipients in selected countries outside of Europe and North America: A systematic review. Transpl Infect Dis 2023; 25:e14070. [PMID: 37254966 DOI: 10.1111/tid.14070] [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: 02/21/2023] [Revised: 04/17/2023] [Accepted: 05/06/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a frequent infectious complication following solid organ transplantation (SOT). Considering significant differences in healthcare systems, a systematic review was conducted to describe the epidemiology, management, and burden of CMV post-SOT in selected countries outside of Europe and North America. METHODS MEDLINE, Embase, and Cochrane databases were searched for observational studies in SOT recipients across 15 countries in the regions of Asia, Pacific, and Latin America (search period: January 1, 2011 to September 17, 2021). Outcomes included incidence of CMV infection/disease, recurrence, risk factors, CMV-related mortality, treatment patterns and guidelines, refractory and/or resistant CMV, patient-reported outcomes, and economic burden. RESULTS Of 2708 studies identified, 49 were eligible (n = 43/49; 87.8% in adults; n = 34/49, 69.4% in kidney recipients). Across studies, selection of CMV preventive strategy was based on CMV serostatus. Overall, rates of CMV infection (within 1 year) and CMV disease post-SOT were respectively, 10.3%-63.2% (9 studies) and 0%-19.0% (17 studies). Recurrence occurred in 35.4%-41.0% cases (3 studies) and up to 5.3% recipients died of CMV-associated causes (11 studies). Conventional treatments for CMV infection/disease included ganciclovir (GCV) or valganciclovir. Up to 4.4% patients were resistant to treatment (3 studies); no studies reported on refractory CMV. Treatment-related adverse events with GCV included neutropenia (2%-29%), anemia (13%-48%), leukopenia (11%-37%), and thrombocytopenia (13%-24%). Data on economic burden were scarce. CONCLUSION Outside of North America and Europe, rates of CMV infection/disease post-SOT are highly variable and CMV recurrence is frequent. CMV resistance and treatment-associated adverse events, including myelosuppression, highlight unmet needs with conventional therapy.
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Affiliation(s)
| | - Yaman Tokat
- International Liver Center & Acibadem Healthcare Hospitals, Istanbul, Turkey
| | - Jinzhen Cai
- Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Anudeep Sandhu
- Takeda Pharmaceuticals International AG-Singapore Branch, Singapore, Singapore
| | - Dirk Demuth
- Takeda Pharmaceuticals International AG-Singapore Branch, Singapore, Singapore
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Melenotte C, Aimanianda V, Slavin M, Aguado JM, Armstrong-James D, Chen YC, Husain S, Van Delden C, Saliba F, Lefort A, Botterel F, Lortholary O. Invasive aspergillosis in liver transplant recipients. Transpl Infect Dis 2023:e14049. [PMID: 36929539 DOI: 10.1111/tid.14049] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries. METHODS We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions. RESULTS The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units. CONCLUSION IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.
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Affiliation(s)
- Cléa Melenotte
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France
| | - Monica Slavin
- Department of Infectious Diseases, National Center for Infections in Cancer, Sir Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, University of Melbourne, Melbourne, Australia
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shahid Husain
- Department of Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Agnès Lefort
- Université de Paris, IAME, UMR 1137, INSERM, Paris, France.,Service de Médecine Interne, Hôpital Beaujon, AP-HP, Clichy, France
| | - Francoise Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine, Créteil, France.,Unité de Parasitologie-Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, Créteil, France
| | - Olivier Lortholary
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France.,Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France.,Paris University, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, AP-HP, IHU Imagine, Paris, France
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Huang SF, Huang YC, Lee CT, Chou KT, Chen HP, Huang CC, Ji DD, Chan YJ, Yang YY. Cytomegalovirus viral interleukin-10 (cmvIL-10) in patients with Aspergillus infection and effects on clinical outcome. Mycoses 2022; 65:760-769. [PMID: 35559581 DOI: 10.1111/myc.13472] [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: 03/28/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Human cytomegalovirus (CMV) is associated with aspergillosis, but the simultaneous presence of cytomegalovirus viral interleukin-10 (cmvIL-10) and aspergillosis has never been investigated. CmvIL-10 is produced by CMV-infected cells and acts as an immune modulator during CMV infection. The aim of this study was to evaluate cmvIL-10 levels in peripheral blood and its influence on the clinical outcomes of Aspergillus infection. METHODS Patients who visited or were admitted to the hospital with suspected Aspergillus infection, including invasive aspergillosis (IA) and chronic pulmonary aspergillosis (CPA), were prospectively enrolled. The cmvIL-10, human IL-10 (hIL-10), IL-1B, IL-6, IL-8, IFN-γ, and TNF-α levels in peripheral blood were measured. RESULTS Patients with Aspergillus infection had a higher level of cmvIL-10 than the control group (158±305 vs. 27.9±30.4 pg/mL, p<0.05). The level of cmvIL-10 was not correlated with CMV viremia or end-organ disease. The cmvIL-10 but not hIL-10 level was positively correlated with the IFN-γ level (p<0.05) and marginally negatively correlated with IL-1B and IL-8 levels (p<0.1). In patients with CPA, a high level of cmvIL-10 (≥100 pg/mL) was a poor prognostic factor for long-term survival (p<0.05). In contrast, CMV viremia or end-organ disease was associated with poor survival in patients with IA (p=0.05). CONCLUSIONS Aspergillus infection was associated with CMV coinfection with cmvIL-10 in blood. A cmvIL-10 concentration ≥100 pg/mL was a predictor for unfavourable outcome in CPA patients.
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Affiliation(s)
- Shiang-Fen Huang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taiepi.,School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yu-Chi Huang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taiepi
| | - Chen-Te Lee
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taiepi
| | - Kun-Ta Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
| | - Hsin-Pai Chen
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taiepi.,School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chia-Chang Huang
- Division of General Medicine, Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei.,Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei
| | - Dar-Der Ji
- Department of Tropical Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yu-Juin Chan
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei
| | - Ying-Ying Yang
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei.,Institute of Clinical Medicine, Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Calderón-Parra J, Moreno-Torres V, Mills-Sanchez P, Tejado-Bravo S, Romero-Sánchez I, Balandin-Moreno B, Calvo-Salvador M, Portero-Azorín F, García-Masedo S, Muñez-Rubio E, Ramos-Martinez A, Fernández-Cruz A. Association of COVID-19-Associated Pulmonary Aspergillosis with Cytomegalovirus Replication: A Case–control Study. J Fungi (Basel) 2022; 8:jof8020161. [PMID: 35205914 PMCID: PMC8877274 DOI: 10.3390/jof8020161] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/30/2022] [Accepted: 02/01/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction: Cytomegalovirus (CMV) infection is a well-known factor associated with invasive aspergillosis in immunocompromised hosts. However, its association with COVID-19-associated pulmonary aspergillosis (CAPA) has not been described. We aimed to examine the possible link between CMV replication and CAPA occurrence. Methods: A single-center, retrospective case–control study was conducted. A case was defined as a patient diagnosed with CAPA according to 2020 ECMM/ISHAM consensus criteria. Two controls were selected for each case among critically ill COVID-19 patients. Results: In total, 24 CAPA cases were included, comprising 14 possible CAPA and 10 probable CAPA. Additionally, 48 matched controls were selected. CMV replication was detected more frequently in CAPA than in controls (75.0% vs. 35.4%, p = 0.002). Probable CMV end-organ disease was more prevalent in CAPA (20.8% vs. 4.2%, p = 0.037). After adjusting for possible confounding factors, CMV replication persisted strongly associated with CAPA (OR 8.28 95% CI 1.90–36.13, p = 0.005). Among 11 CAPA cases with CMV PCR available prior to CAPA, in 9 (81.8%) cases, CMV replication was observed prior to CAPA diagnosis. Conclusions: Among critically ill COVID-19 patients, CMV replication was associated with CAPA and could potentially be considered a harbinger of CAPA. Further studies are needed to confirm this association.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
- Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA), 28222 Madrid, Spain
- Correspondence:
| | - Victor Moreno-Torres
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
- Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA), 28222 Madrid, Spain
| | - Patricia Mills-Sanchez
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
| | - Sandra Tejado-Bravo
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (S.T.-B.); (B.B.-M.)
| | - Isabel Romero-Sánchez
- Microbiology Service, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain;
| | - Bárbara Balandin-Moreno
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (S.T.-B.); (B.B.-M.)
| | - Marina Calvo-Salvador
- Pharmacy Service, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (M.C.-S.); (F.P.-A.); (S.G.-M.)
| | - Francisca Portero-Azorín
- Pharmacy Service, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (M.C.-S.); (F.P.-A.); (S.G.-M.)
| | - Sarela García-Masedo
- Pharmacy Service, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (M.C.-S.); (F.P.-A.); (S.G.-M.)
| | - Elena Muñez-Rubio
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
| | - Antonio Ramos-Martinez
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
| | - Ana Fernández-Cruz
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (V.M.-T.); (P.M.-S.); (E.M.-R.); (A.R.-M.); (A.F.-C.)
- Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA), 28222 Madrid, Spain
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