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Kamel S, Corbacho-Loarte MD, Escudero-Sánchez R, Halperin A, Llorente S, Quevedo SM, Suárez-Carantoña C, del Campo L, Hernández MS, Guillen SM, Cobo J. Impact of an Intervention Program on Clostridioides difficile Infections: Comparison of 2 Hospital Cohorts. Open Forum Infect Dis 2024; 11:ofae390. [PMID: 39050227 PMCID: PMC11267231 DOI: 10.1093/ofid/ofae390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Indexed: 07/27/2024] Open
Abstract
Background Clostridioides difficile infection (CDI) occurs in various contexts and care settings and is managed by multiple specialists who are not experts in its management. While there are many initiatives to improve the diagnosis and avoid overdiagnosis, there is less focus on the overall management of the infection. Methods We studied a cohort of patients with a positive test result for toxigenic C difficile in 2 hospitals. Hospital A has a program that provides advice from an infectious disease specialist (IDS) and promotes continuity of care by providing a phone number to contact the IDS. Hospital B does not have any specific CDI program. The evaluation assessed the proportion of patients not treated (carriers or self-limited disease), adherence to Infectious Diseases Society of America guidelines, access to novel therapies, recurrence and mortality rates, and readmission and emergency department visits due to CDI. We assessed the program's effectiveness through a logistic regression model adjusted for covariates chosen by clinical criteria. Results Hospital A avoided more unnecessary treatments (19.3% vs 11.5%), provided access to novel therapies more frequently (35.3% vs 13%), and adhered more closely to current guidelines (95.8% vs 71.3%). Although the mortality and recurrence rates did not differ, the absence of an intervention program was associated with greater odds of admission due to recurrence (odds ratio, 4.19; P = .037) and more visits to the emergency department due to CDI (odds ratio, 8.74; P = .001). Conclusions Implementation of a CDI intervention program based on recommendations from IDSs and improved access to specialized care during the follow-up is associated with enhanced quality of CDI management and potential reductions in hospital resource utilization.
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Affiliation(s)
- Sara Kamel
- Internal Medicine Department, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - María Dolores Corbacho-Loarte
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosa Escudero-Sánchez
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Halperin
- Microbiology Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Sergio Llorente
- Internal Medicine Department, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Sara María Quevedo
- Microbiology Department, Hospital Universitario Severo Ochoa, IRYCIS, Madrid, Spain
| | - Cecilia Suárez-Carantoña
- IInternal Medicine Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- Medicine Department, Alcalá University, Madrid, Spain
| | - Laura del Campo
- Biostatistics Department, CIBERESP, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Epidemiologia y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Santiago Moreno Guillen
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Alcalá University, Madrid, Spain
| | - Javier Cobo
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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2
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Iftimie S, López-Azcona AF, Corchero-Valverde M, Peralta-Vázquez A, López-Cordón LR, García-Cervera C, Fernández-Domínguez LM, Camps J, Joven J, Castro A. Retrospective Analysis of Clostridioides difficile Infection Rates and Outcomes in Hospitalized Patients during the COVID-19 Pandemic: A Unicenter Study in Reus, Spain. J Clin Med 2024; 13:2799. [PMID: 38792341 PMCID: PMC11122305 DOI: 10.3390/jcm13102799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background:Clostridioides difficile infections (CDI) vary in severity from mild diarrhea to life-threatening conditions like pseudomembranous colitis or toxic megacolon, often leading to sepsis and death. The COVID-19 pandemic prompted changes in healthcare practices, potentially affecting CDI incidence, though reported data are inconclusive. We studied factors influencing CDI incidence and outcomes at a university hospital throughout the COVID-19 pandemic years. Methods: We conducted a retrospective study on all adult hospitalized CDI cases from 1 January 2020 to 31 December 2022 in Hospital Universitari de Sant Joan in Reus. We collected demographic information, comorbid conditions, and concurrent infections. Results: While overall CDI and COVID-19 rates decreased in 2022, a notable increase in CDI infections was observed among oncological patients and those undergoing some aggressive treatments, such as colonoscopies or gastroscopies. The prevalence of comorbidities remained unmodified, and there were declines in prior gastrointestinal surgeries and proton pump inhibitor prescriptions. Factors associated with patient fatality or prolonged hospitalization included older age, cancer, chronic kidney disease, higher Charlson and McCabe indices, elevated C-reactive protein, and low albumin concentrations. Conclusions: Our study shows the evolving landscape of CDI during the COVID-19 pandemic and emphasizes the impact of delayed diagnoses and treatments exacerbated by telemedicine adoption. Identified risk factors for CDI-related mortality or prolonged hospital stays underscore the importance of targeted interventions in high-risk populations.
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Affiliation(s)
- Simona Iftimie
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | - Ana F. López-Azcona
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | - Mireia Corchero-Valverde
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | - Antonio Peralta-Vázquez
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | - Laia Revuelta López-Cordón
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | - Carles García-Cervera
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
| | | | - Jordi Camps
- Unitat de Recerca Biomèdica, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain;
| | - Jorge Joven
- Unitat de Recerca Biomèdica, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain;
| | - Antoni Castro
- Department of Internal Medicine, Institut d’Investigació Sanitària Pere Virgili, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43204 Reus, Spain; (S.I.); (A.F.L.-A.); (M.C.-V.); (A.P.-V.); (L.R.L.-C.); (C.G.-C.); (A.C.)
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Reigadas E, Vázquez-Cuesta S, Bouza E. Economic Burden of Clostridioides difficile Infection in European Countries. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:1-12. [PMID: 38175468 DOI: 10.1007/978-3-031-42108-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile infection (CDI) remains a considerable challenge to healthcare systems worldwide. Although CDI represents a significant burden on healthcare systems in Europe, few studies have attempted to estimate the consumption of resources associated with CDI in Europe. The reported extra costs attributable to CDI vary widely according to the definitions, design, and methodologies used, making comparisons difficult to perform. In this chapter, the economic burden of healthcare facility-associated CDI in Europe will be assessed, as will other less explored areas such as the economic burden of recurrent CDI, community-acquired CDI, pediatric CDI, and CDI in outbreaks.
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Affiliation(s)
- Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
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de la Villa S, Herrero S, Muñoz P, Rodríguez C, Valerio M, Reigadas E, Álvarez-Uría A, Alcalá L, Marín M, Olmedo M, Kestler M, Chamorro E, Bouza E. Real-world Use of Bezlotoxumab and Fecal Microbiota Transplantation for the Treatment of Clostridioides difficile Infection. Open Forum Infect Dis 2023; 10:ofad028. [PMID: 36776780 PMCID: PMC9907541 DOI: 10.1093/ofid/ofad028] [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: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
Background We aimed to describe the frequency of use and effectiveness of bezlotoxumab (BZX) and fecal microbiota transplantation (FMT) in patients with Clostridioides difficile infection (CDI) in real-world practice. Methods This was a retrospective study conducted in a university hospital in which adult patients treated with BZX or FMT from January 2018 to April 2021 were included. The primary objective was to evaluate the effectiveness of BZX and FMT in preventing early (within 8 weeks) and late (within 1 year) CDI recurrences (rCDI). A multivariate analysis of risk factors for early recurrence was performed. Results Of 1377 consecutive CDI episodes, 117 (8.5%) received BZX or FMT, with full information available for 100 of the episodes: 51 received BZX, and 49 received FMT. BZX was used mostly in immunosuppressed patients (66.7%) and in first episodes or first recurrences in 70.6% of the cases. FMT was prescribed only in CDI recurrences. Despite the different conditions of the patients, there were no significant differences between BZX and FMT in preventing early rCDI (19.6% vs 24.5%; P = .55) or late rCDI (9.8% vs 18.4%; P = .31). In the multivariate analysis, risk factors for recurrence were presence of ≥2 previous rCDI episodes (odds ratio [OR], 2.90; 95% CI, 1.03-8.63) and use of non-CDI antibiotics (OR, 3.45; 95% CI, 1.24-9.57). Conclusions BZX and FMT were infrequently used in real-world practice. Both treatments had similar effectiveness in preventing CDI recurrence despite their application to different populations.
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Affiliation(s)
- Sofía de la Villa
- Correspondence: Sofía de la Villa, MD, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain (); or Patricia Muñoz, MD, PhD, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain ()
| | - Sergio Herrero
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Correspondence: Sofía de la Villa, MD, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain (); or Patricia Muñoz, MD, PhD, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain ()
| | - Carmen Rodríguez
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Elena Reigadas
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Álvarez-Uría
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Luis Alcalá
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Mercedes Marín
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Olmedo
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Esther Chamorro
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain,Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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5
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Guery B, Reinoso JC. Optimising Antimicrobial Stewardship to Tackle Clostridioides difficile Infection and Improve Patient Outcomes. EMJ MICROBIOLOGY & INFECTIOUS DISEASES 2022. [DOI: 10.33590/emjmicrobiolinfectdis/10107151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Clostridioides difficile, formerly known as Clostridium difficile, is a Gram-positive spore-forming and toxin-producing bacterium that causes diarrhoea in vulnerable patient groups. It is a common hospital-acquired infection but also occurs in the community. Typically, C. difficile colonises the gut in patients experiencing gut dysbiosis, for example, following antimicrobial treatment or chemotherapy. Cases of C. difficile are increasing worldwide, both in healthcare settings and in the community, and are an indicator of widespread antibiotic use. Antimicrobial stewardship (AMS) combines local, national, and international guidelines for good antimicrobial practice, effective monitoring of antimicrobial resistance, and control of antibiotic use. Such strategies are vital in the international drive to stem the rise in antimicrobial resistance and control hospital-acquired infections such as C. difficile. However, implementation of such strategies is often lacking. Resourcing issues and a lack of awareness of current best practices among physicians, prescribers, and the general public are significant barriers to implementation. EMJ spoke with two infectious disease experts: Benoît Guery, University Hospital of Lausanne, Switzerland, and Javier Cobo Reinoso, Hospital Universitario Ramón y Cajal, Madrid, Spain. They highlighted the challenges that face medical practitioners, infectious disease experts, hospital managers, and healthcare providers in developing and implementing effective antimicrobial strategies that support better patient outcomes. The two experts also discussed the changes required to ensure that good AMS can be implemented at local, national, and international levels.
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Darwich L, Seminati C, López-Olvera JR, Vidal A, Aguirre L, Cerdá M, Garcias B, Valldeperes M, Castillo-Contreras R, Migura-Garcia L, Conejero C, Mentaberre G. Detection of Beta-Lactam-Resistant Escherichia coli and Toxigenic Clostridioides difficile Strains in Wild Boars Foraging in an Anthropization Gradient. Animals (Basel) 2021; 11:ani11061585. [PMID: 34071332 PMCID: PMC8229602 DOI: 10.3390/ani11061585] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
Disease transmission among wild boars, domestic animals and humans is a public health concern, especially in areas with high wild boar densities. In this study, fecal samples of wild boars (n = 200) from different locations of the Metropolitan Area of Barcelona were analyzed by PCR to explore the frequency of β-lactamases and extended cephalosporin and carbapenem resistance genes (ESBLs) in Escherichia coli strains and the presence of toxigenic Clostridioides difficile. The prevalence of genes conferring resistance to β-lactam antimicrobials was 8.0% (16/200): blaCMY-2 (3.0%), blaTEM-1b (2.5%), blaCTX-M-14 (1.0%), blaSHV-28 (1.0%), blaCTX-M-15 (0.5%) and blaCMY-1 (0.5%). Clostridioides difficile TcdA+ was detected in two wild boars (1.0%), which is the first report of this pathogen in wild boars in Spain. Moreover, the wild boars foraging in urban and peri-urban locations were more exposed to AMRB sources than the wild boars dwelling in natural environments. In conclusion, the detection of E. coli carrying ESBL/AmpC genes and toxigenic C. difficile in wild boars foraging in urban areas reinforces the value of this game species as a sentinel of environmental AMRB sources. In addition, these wild boars can be a public and environmental health concern by disseminating AMRB and other zoonotic agents. Although this study provides the first hints of the potential anthropogenic sources of AMR, further efforts should be conducted to identify and control them.
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Affiliation(s)
- Laila Darwich
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, CP-08193 Cerdanyola del Vallès, Spain;
- OIE Collaborating Centre for the Research and Control of Emerging and Re-emerging Swine Diseases in Eu-rope (IRTA-CReSA), Bellaterra, CP-08193 Barcelona, Spain
- Correspondence: (L.D.); (C.S.); Tel.: +34-935811046 (L.D. & C.S.)
| | - Chiara Seminati
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
- Correspondence: (L.D.); (C.S.); Tel.: +34-935811046 (L.D. & C.S.)
| | - Jorge R. López-Olvera
- Wildlife Ecology & Health Group (WE&H) and Servei d’Ecopatologia de Fauna Salvatge (SEFaS), Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (J.R.L.-O.); (M.V.); (R.C.-C.); (C.C.); (G.M.)
| | - Anna Vidal
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
| | - Laia Aguirre
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
| | - Marina Cerdá
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
| | - Biel Garcias
- Departament de Sanitat i Anatomia Animal, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (A.V.); (L.A.); (M.C.); (B.G.)
| | - Marta Valldeperes
- Wildlife Ecology & Health Group (WE&H) and Servei d’Ecopatologia de Fauna Salvatge (SEFaS), Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (J.R.L.-O.); (M.V.); (R.C.-C.); (C.C.); (G.M.)
| | - Raquel Castillo-Contreras
- Wildlife Ecology & Health Group (WE&H) and Servei d’Ecopatologia de Fauna Salvatge (SEFaS), Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (J.R.L.-O.); (M.V.); (R.C.-C.); (C.C.); (G.M.)
| | - Lourdes Migura-Garcia
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, CP-08193 Cerdanyola del Vallès, Spain;
- OIE Collaborating Centre for the Research and Control of Emerging and Re-emerging Swine Diseases in Eu-rope (IRTA-CReSA), Bellaterra, CP-08193 Barcelona, Spain
| | - Carles Conejero
- Wildlife Ecology & Health Group (WE&H) and Servei d’Ecopatologia de Fauna Salvatge (SEFaS), Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (J.R.L.-O.); (M.V.); (R.C.-C.); (C.C.); (G.M.)
| | - Gregorio Mentaberre
- Wildlife Ecology & Health Group (WE&H) and Servei d’Ecopatologia de Fauna Salvatge (SEFaS), Departament de Medicina i Cirurgia Animals, Universitat Autònoma de Barcelona (UAB), CP-08193 Cerdanyola del Vallès, Spain; (J.R.L.-O.); (M.V.); (R.C.-C.); (C.C.); (G.M.)
- Departament de Ciència Animal, Escola Tècnica Superior d’Enginyeria Agraria (ETSEA), Universitat de Lleida (UdL), CP-25098 Lleida, Spain
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