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Islam MM, Mahbub NU, Shin WS, Oh MH. Phage-encoded depolymerases as a strategy for combating multidrug-resistant Acinetobacter baumannii. Front Cell Infect Microbiol 2024; 14:1462620. [PMID: 39512587 PMCID: PMC11540826 DOI: 10.3389/fcimb.2024.1462620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 09/26/2024] [Indexed: 11/15/2024] Open
Abstract
Acinetobacter baumannii, a predominant nosocomial pathogen, represents a grave threat to public health due to its multiple antimicrobial resistance. Managing patients afflicted with severe infections caused by multiple drug-resistant A. baumannii is particularly challenging, given the associated high mortality rates and unfavorable prognoses. The diminishing efficacy of antibiotics against this superbug underscores the urgent necessity for novel treatments or strategies to address this formidable issue. Bacteriophage-derived polysaccharide depolymerase enzymes present a potential approach to combating this pathogen. These enzymes target and degrade the bacterial cell's exopolysaccharide, capsular polysaccharide, and lipopolysaccharide, thereby disrupting biofilm formation and impairing the bacteria's defense mechanisms. Nonetheless, the narrow host range of phage depolymerases limits their therapeutic efficacy. Despite the benefits of these enzymes, phage-resistant strains have been identified, highlighting the complexity of phage-host interactions and the need for further investigation. While preliminary findings are encouraging, current investigations are limited, and clinical trials are imperative to advance this treatment approach for broader clinical applications. This review explores the potential of phage-derived depolymerase enzymes against A. baumannii infections.
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Affiliation(s)
- Md Minarul Islam
- Department of Microbiology, College of Science and Technology, Dankook University, Cheonan, Republic of Korea
- Smart Animal Bio Institute, Dankook University, Cheonan, Republic of Korea
| | - Nasir Uddin Mahbub
- Department of Biomedical Sciences and Institute for Medical Science, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Woo Shik Shin
- Department of Pharmaceutical Sciences, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Man Hwan Oh
- Department of Microbiology, College of Science and Technology, Dankook University, Cheonan, Republic of Korea
- Smart Animal Bio Institute, Dankook University, Cheonan, Republic of Korea
- Center for Bio-Medical Engineering Core Facility, Dankook University, Cheonan, Republic of Korea
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2
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Teymouri S, Pourhajibagher M, Bahador A. A review of the fighting Acinetobacter baumannii on three fronts: antibiotics, phages, and nanoparticles. Mol Biol Rep 2024; 51:1044. [PMID: 39377967 DOI: 10.1007/s11033-024-09979-4] [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: 02/28/2024] [Accepted: 09/30/2024] [Indexed: 02/06/2025]
Abstract
In the current era of antibiotic resistance, researchers are exploring alternative ways to treat bacterial infections that are resistant to multiple drugs. Acinetobacter baumannii (A. baumannii) is a bacterium that is commonly encountered in clinical settings and is known to be resistant to several drugs. Due to the increase in drug-resistant infections caused by this bacteria, there is an urgent need to investigate alternative treatment options such as phage therapy and combination therapy. Despite the success of phages in some cases, there are some limitations in their clinical application that can be overcome by combining phages with other substrates such as nanoparticles to improve their function. The integration of nanotechnology with phage therapy against A. baumannii promises to overcome antibiotic resistance. By exploiting the targeted delivery and controlled release capabilities of nanoparticles, we can enhance the therapeutic potential of phages while minimizing their limitations. Continued research in this field will undoubtedly pave the way for more effective and precise treatments against A. baumannii infections and provide hope in the fight against antibiotic-resistant bacteria.
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Affiliation(s)
- Samane Teymouri
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Pourhajibagher
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
- Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Abbas Bahador
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
- Fellowship in Clinical Laboratory Sciences, BioHealth Lab, Tehran, Iran.
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Narayanan MP, Kumar A, Kumar Verma G, Bairwa A, Mirza AA, Goyal B. Efficacy of Bacteriophages in Wound Healing: An Updated Review. Cureus 2024; 16:e71542. [PMID: 39544596 PMCID: PMC11563050 DOI: 10.7759/cureus.71542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 11/17/2024] Open
Abstract
We have attempted to summarize the efficacy of bacteriophage therapy, highlighting the recent advances and phage delivery methods in different clinical trials and animal studies for wound-associated infections. Bacteriophage therapy is the lyse of bacteria by bacteriophages at the site of invasion. As bacteria become more resistant to antibiotics, discovering an alternative is more important than ever, and bacteriophage therapy has yielded promising outcomes. A clear knowledge of the bacteriophage, microbiota, and human host and their interaction is necessary to implement bacteriophage treatment on a large scale. Much technological advancement and regulatory guidelines increased the credibility of phage therapy (PT). Still, the challenges include the development of efficient bacteriophage screening methods, phage therapy strategies for biofilms, and the quality and safety of phage preparations. However, much consideration is to be taken in designing a novel therapeutic approach for antibiotic-resistant infections by using phages, phage lytic proteins, bioengineered phages, or antibiotics in combination.
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Affiliation(s)
- M P Narayanan
- Biochemistry, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ankur Kumar
- Microbiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ganesh Kumar Verma
- Biochemistry, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Avinash Bairwa
- Biochemistry, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Anissa A Mirza
- Biochemistry, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Bela Goyal
- Biochemistry, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Pal N, Sharma P, Kumawat M, Singh S, Verma V, Tiwari RR, Sarma DK, Nagpal R, Kumar M. Phage therapy: an alternative treatment modality for MDR bacterial infections. Infect Dis (Lond) 2024; 56:785-817. [PMID: 39017931 DOI: 10.1080/23744235.2024.2379492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
The increasing global incidence of multidrug-resistant (MDR) bacterial infections threatens public health and compromises various aspects of modern medicine. Recognising the urgency of this issue, the World Health Organisation has prioritised the development of novel antimicrobials to combat ESKAPEE pathogens. Comprising Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp. and Escherichia coli, such pathogens represent a spectrum of high to critical drug resistance, accounting for a significant proportion of hospital-acquired infections worldwide. In response to the waning efficacy of antibiotics against these resilient pathogens, phage therapy (PT) has emerged as a promising therapeutic strategy. This review provides a comprehensive summary of clinical research on PT and explores the translational journey of phages from laboratory settings to clinical applications. It examines recent advancements in pre-clinical and clinical developments, highlighting the potential of phages and their proteins, alone or in combination with antibiotics. Furthermore, this review underlines the importance of establishing safe and approved routes of phage administration to patients. In conclusion, the evolving landscape of phage therapy offers a beacon of hope in the fight against MDR bacterial infections, emphasising the imperative for continued research, innovation and regulatory diligence to realise its full potential in clinical practice.
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Affiliation(s)
- Namrata Pal
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
- Department of Microbiology, Barkatullah University, Bhopal, Madhya Pradesh, India
| | - Poonam Sharma
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Manoj Kumawat
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Samradhi Singh
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Vinod Verma
- Stem Cell Research Centre, Department of Hematology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajnarayan R Tiwari
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Devojit Kumar Sarma
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Ravinder Nagpal
- Department of Nutrition and Integrative Physiology, College of Health and Human Sciences, Florida State University, Tallahassee, FL, USA
| | - Manoj Kumar
- Department of Microbiology, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
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Naseef Pathoor N, Viswanathan A, Wadhwa G, Ganesh PS. Understanding the biofilm development of Acinetobacter baumannii and novel strategies to combat infection. APMIS 2024; 132:317-335. [PMID: 38444124 DOI: 10.1111/apm.13399] [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: 12/08/2023] [Accepted: 02/22/2024] [Indexed: 03/07/2024]
Abstract
Acinetobacter baumannii (A. baumannii) is a Gram-negative, nonmotile, and aerobic bacillus emerged as a superbug, due to increasing the possibility of infection and accelerating rates of antimicrobial agents. It is recognized as a nosocomial pathogen due to its ability to form biofilms. These biofilms serve as a defensive barrier, increase antibiotic resistance, and make treatment more difficult. As a result, the current situation necessitates the rapid emergence of novel therapeutic approaches to ensure successful treatment outcomes. This review explores the intricate relationship between biofilm formation and antibiotic resistance in A. baumannii, emphasizing the role of key virulence factors and quorum sensing (QS) mechanisms that will lead to infections and facilitate insight into developing innovative method to control A. baumannii infections. Furthermore, the review article looks into promising approaches for preventing biofilm formation on medically important surfaces and potential therapeutic methods for eliminating preformed biofilms, which can address biofilm-associated A. baumannii infections. Modern advances in emerging therapeutic options such as antimicrobial peptide (AMPs), nanoparticles (NPs), bacteriophage therapy, photodynamic therapy (PDT), and other biofilm inhibitors can assist readers understand the current landscape and future prospects for effectively treating A. baumannii biofilm infections.
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Affiliation(s)
- Naji Naseef Pathoor
- Department of Microbiology, Centre for Infectious Diseases, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University (Deemed to be University), Chennai, Tamil Nadu, India
| | - Akshaya Viswanathan
- Department of Microbiology, Centre for Infectious Diseases, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University (Deemed to be University), Chennai, Tamil Nadu, India
| | - Gulshan Wadhwa
- Department of Biotechnology, Ministry of Science and Technology, New Delhi, India
| | - Pitchaipillai Sankar Ganesh
- Department of Microbiology, Centre for Infectious Diseases, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University (Deemed to be University), Chennai, Tamil Nadu, India
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Bouza E, Muñoz P, Burillo A. How to treat severe Acinetobacter baumannii infections. Curr Opin Infect Dis 2023; 36:596-608. [PMID: 37930071 DOI: 10.1097/qco.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW To update the management of severe Acinetobacter baumannii infections (ABI), particularly those caused by multi-resistant isolates. RECENT FINDINGS The in vitro activity of the various antimicrobial agents potentially helpful in treating ABI is highly variable and has progressively decreased for many of them, limiting current therapeutic options. The combination of more than one drug is still advisable in most circumstances. Ideally, two active first-line drugs should be used. Alternatively, a first-line and a second-line drug and, if this is not possible, two or more second-line drugs in combination. The emergence of new agents such as Cefiderocol, the combination of Sulbactam and Durlobactam, and the new Tetracyclines offer therapeutic options that need to be supported by clinical evidence. SUMMARY The apparent limitations in treating infections caused by this bacterium, the rapid development of resistance, and the serious underlying situation in most cases invite the search for alternatives to antibiotic treatment, the most promising of which seems to be bacteriophage therapy.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute
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Wang M, Ning Y, Jiao X, Liu J, Qiao J. Bacteriophages and their derived enzymes as promising alternatives for the treatment of Acinetobacter baumannii infections. Arch Virol 2023; 168:288. [PMID: 37947926 DOI: 10.1007/s00705-023-05910-7] [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] [Received: 06/11/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023]
Abstract
Nosocomial infections with the opportunistic bacterium Acinetobacter baumannii pose a severe challenge to clinical treatment, which is aggravated by the increasing occurrence of multi-drug resistance, especially resistance to carbapenems. The use of phage therapy as an alternative and supplement to the current antibiotics has become an important research topic in the post-antibiotic era. This review summarizes in vivo and in vitro studies on phage therapy against multi-drug-resistant A. baumannii infection that have used different approaches, including treatment with a single phage, combination with other phages or non-phage agents, and administration of phage-derived enzymes. We also briefly discuss the current challenges of phage-based therapy as well as promising approaches for the treatment of A. baumannii infection in the future.
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Affiliation(s)
- Menglu Wang
- Department of Medical Laboratory, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China
| | - Yu Ning
- Department of Medical Laboratory, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China
| | - Xin Jiao
- Department of Medical Laboratory, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China
| | - Jiayi Liu
- Department of Medical Laboratory, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China
- Department of Basic Medicine, Weifang Nursing Vocational College, Weifang, 262500, Shandong, People's Republic of China
| | - Jinjuan Qiao
- Department of Medical Laboratory, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China.
- Institutional Key Laboratory of Clinical Laboratory Diagnostics, 12th 5-Year Project of Shandong Province, Weifang Medical University, Weifang, 261053, Shandong, People's Republic of China.
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Karn SL, Gangwar M, Kumar R, Bhartiya SK, Nath G. Phage therapy: a revolutionary shift in the management of bacterial infections, pioneering new horizons in clinical practice, and reimagining the arsenal against microbial pathogens. Front Med (Lausanne) 2023; 10:1209782. [PMID: 37928478 PMCID: PMC10620811 DOI: 10.3389/fmed.2023.1209782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
The recent approval of experimental phage therapies by the FDA and other regulatory bodies with expanded access in cases in the United States and other nations caught the attention of the media and the general public, generating enthusiasm for phage therapy. It started to alter the situation so that more medical professionals are willing to use phage therapies with conventional antibiotics. However, more study is required to fully comprehend phage therapy's potential advantages and restrictions, which is still a relatively new field in medicine. It shows promise, nevertheless, as a secure and prosperous substitute for antibiotics when treating bacterial illnesses in animals and humans. Because of their uniqueness, phage disinfection is excellent for ready-to-eat (RTE) foods like milk, vegetables, and meat products. The traditional farm-to-fork method can be used throughout the food chain to employ bacteriophages to prevent food infections at all production stages. Phage therapy improves clinical outcomes in animal models and lowers bacterial burdens in numerous preclinical investigations. The potential of phage resistance and the need to make sure that enough phages are delivered to the infection site are obstacles to employing phages in vivo. However, according to preclinical studies, phages appear to be a promising alternative to antibiotics for treating bacterial infections in vivo. Phage therapy used with compassion (a profound understanding of and empathy for another's suffering) has recently grown with many case reports of supposedly treated patients and clinical trials. This review summarizes the knowledge on the uses of phages in various fields, such as the food industry, preclinical research, and clinical settings. It also includes a list of FDA-approved bacteriophage-based products, commercial phage products, and a global list of companies that use phages for therapeutic purposes.
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Affiliation(s)
- Subhash Lal Karn
- Department of Microbiology, Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Mayank Gangwar
- Department of Microbiology, Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rajesh Kumar
- Department of Microbiology, Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Satyanam Kumar Bhartiya
- Department of General Surgery, Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Gopal Nath
- Department of Microbiology, Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Tu Q, Pu M, Li Y, Wang Y, Li M, Song L, Li M, An X, Fan H, Tong Y. Acinetobacter Baumannii Phages: Past, Present and Future. Viruses 2023; 15:v15030673. [PMID: 36992382 PMCID: PMC10057898 DOI: 10.3390/v15030673] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/23/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Acinetobacter baumannii (A. baumannii) is one of the most common clinical pathogens and a typical multi-drug resistant (MDR) bacterium. With the increase of drug-resistant A. baumannii infections, it is urgent to find some new treatment strategies, such as phage therapy. In this paper, we described the different drug resistances of A. baumannii and some basic properties of A. baumannii phages, analyzed the interaction between phages and their hosts, and focused on A. baumannii phage therapies. Finally, we discussed the chance and challenge of phage therapy. This paper aims to provide a more comprehensive understanding of A. baumannii phages and theoretical support for the clinical application of A. baumannii phages.
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Affiliation(s)
- Qihang Tu
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Mingfang Pu
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Yahao Li
- Beijing Advanced Innovation Center for Soft Matter Science and Engineering (BAIC-SM), Beijing University of Chemical Technology, Beijing 100029, China
| | - Yuer Wang
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Maochen Li
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Lihua Song
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Mengzhe Li
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Xiaoping An
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Huahao Fan
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
- Correspondence: (H.F.); (Y.T.)
| | - Yigang Tong
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
- Beijing Advanced Innovation Center for Soft Matter Science and Engineering (BAIC-SM), Beijing University of Chemical Technology, Beijing 100029, China
- Correspondence: (H.F.); (Y.T.)
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Tan Y, Su J, Fu M, Zhang H, Zeng H. Recent Advances in Phage-Based Therapeutics for Multi-Drug Resistant Acinetobacter baumannii. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 10:bioengineering10010035. [PMID: 36671607 PMCID: PMC9855029 DOI: 10.3390/bioengineering10010035] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/10/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
Acinetobacter baumannii is an important opportunistic pathogen common in clinical infections. Phage therapy become a hot research field worldwide again after the post-antibiotic era. This review summarizes the important progress of phage treatments for A. baumannii in the last five years, and focus on the new interesting advances including the combination of phage and other substances (like photosensitizer), and the phage encapsulation (by microparticle, hydrogel) in delivery. We also discuss the remaining challenges and promising directions for phage-based therapy of A. baumannii infection in the future, and the innovative combination of materials in this area may be one promising direction.
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Acinetobacter Baumannii: More Ways to Die. Microbiol Res 2022; 261:127069. [DOI: 10.1016/j.micres.2022.127069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
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