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Rouhi F, Soltani S, Sadeghi S, Nasri E, Hosseini M, Ghafel S, Aboutalebian S, Fakhim H, Mirhendi H. Yeast species in the respiratory samples of COVID-19 patients; molecular tracking of Candida auris. Front Cell Infect Microbiol 2024; 14:1295841. [PMID: 38707510 PMCID: PMC11066282 DOI: 10.3389/fcimb.2024.1295841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 03/29/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Although the existence of Candida species in the respiratory tract is often considered commensal, it is crucial to recognize the significance of Candida colonization in immunocompromised or COVID-19 patients. The emergence of Candida auris as an emerging pathogen further emphasizes the importance of monitoring yeast infection/colonization, particularly in COVID-19 patients. Methods In this study, respiratory samples mainly from COVID-19 patients, primarily those suspected of having a fungal infection, were cultured on Sabouraud dextrose agar plates and the yeast colonies were identified using a two-step multiplex PCR method. The samples suspected of C. auris underwent specific nested PCR followed by sequence analysis. Results A total of 199 respiratory samples were collected from 73 women and 126 men, ranging in age from 1.6 to 88 years. Among the patients, 141 had COVID-19, 32 had cancer, 5 were hospitalized in ICU, 2 had chronic obstructive pulmonary disease)COPD(, and others were patients with combination diseases. From these samples, a total of 334 yeast strains were identified. C. albicans (n=132, 39.52%) was the most common species, followed by C. tropicalis (n=67, 20%), C. glabrata (n=56, 16.76%), C. krusei (n=18, 5.4%), C. parapsilosis (n=17, 5.08%), Saccharomyces cerevisiae (n=10, 3%), C. kefyr (n=9, 2.6%), C. dubliniensis (n=7, 2.1%), C. lusitaniae (n=5, 1.5%), C. auris (n=3, 0.9%), C. guilliermondii (n=2, 0.6%), C. rugosa (n=1, 0.3%), C. intermedia (n=1, 0.3%), and Trichosporon spp. (n=1, 0.3%). C. auris was detected in a patient in ICU and two COVID-19 patients. While its presence was confirmed through sequence analysis, our extensive efforts to isolate C. auris were unsuccessful. Conclusion While C. albicans colonization remains prevalent, our study found no evidence of Candida lung infection. Since the role of Candida colonization in airway secretions remains ambiguous due to limited research, further studies are imperative to shed light on this matter.
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Affiliation(s)
- Faezeh Rouhi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sajedeh Soltani
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Sadeghi
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elahe Nasri
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Hosseini
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Safiyeh Ghafel
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Fakhim
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Mirhendi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
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Yazdanpanah S, Jabrodini A, Motamedi M, Zomorodian K, Kharazi M, Shabanzadeh S, Ghasemi F, Shariat S, Rezaei Arab M. Species distribution and antifungal susceptibility profiles of yeasts isolated from onychomycosis: a cross-sectional study with insights into emerging species. Antonie Van Leeuwenhoek 2023; 117:6. [PMID: 38153531 DOI: 10.1007/s10482-023-01914-0] [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: 10/19/2023] [Accepted: 12/01/2023] [Indexed: 12/29/2023]
Abstract
Candida onychomycosis is a common fungal infection affecting the nails, primarily caused by Candida (C.) species. Regarding the increasing trend of Candida onychomycosis and the antifungal resistant phenomenon in recent years, this study aims to evaluate the epidemiological characteristics of Candida onychomycosis, the distribution of emerging species, and the antifungal susceptibility profiles of isolates. Onychomycosis caused by yeast species was confirmed through direct examination and culture of nail scraping among all individuals suspected to have onychomycosis and referred to a medical mycology laboratory between June 2019 and March 2022. Species of yeast isolates were identified using the multiplex PCR and PCR-RFLP methods. The antifungal susceptibility of isolates to common antifungal agents and imidazole drugs was evaluated according to the M-27-A3 CLSI protocol. Among 101 yeast strains isolated from onychomycosis, Candida parapsilosis complex (50.49%) was the most common species, followed by C. albicans (20.79%) and C. tropicalis (10.89%). Rare species of yeasts such as C. guilliermondii and Saccharomyces cerevisiae were also identified by molecular methods. Results obtained from antifungal susceptibility testing showed significant differences in MIC values of isoconazole, fenticonazole, and sertaconazole among different species. Overall, a fluconazole-resistant rate of 3% was found among Candida species. Moreover, there was a statistically significant difference in MICs of fenticonazole and clotrimazole between the two most prevalent causative species, C. parapsilosis complex and C. albicans. Correct identification of the causative agents of onychomycosis and performing susceptibility testing could be helpful in choosing the most appropriate antifungal therapy.
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Affiliation(s)
- Somayeh Yazdanpanah
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Jabrodini
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marjan Motamedi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahboobeh Kharazi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shafigheh Shabanzadeh
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farnia Ghasemi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sahar Shariat
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Rezaei Arab
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Aboutalebian S, Nikmanesh B, Mohammadpour M, Charsizadeh A, Mirhendi H. Candida palmioleophila candidemia and bacterial co-infection in a 3-month-old infant with biliary atresia. Front Cell Infect Microbiol 2023; 13:1277607. [PMID: 38029248 PMCID: PMC10652749 DOI: 10.3389/fcimb.2023.1277607] [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: 08/14/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Candidemia caused by rare and uncommon Candida species is becoming more prevalent in pediatric healthcare settings, resulting in significant morbidity and mortality. One such species, Candida palmioleophila, is resistant to fluconazole but highly susceptible to echinocandins. Here, we report the first documented case of C. palmioleophila candidemia in Iran that occurred in a male infant with biliary atresia who had been hospitalized for 2 months. The patient's blood and urine cultures were positive for both yeast and bacterial species. Through DNA sequence analysis, the yeast isolate was identified as C. palmioleophila. In vitro antifungal susceptibility testing of the isolate against amphotericin B, fluconazole, itraconazole, voriconazole, isavuconazole, posaconazole, and nystatin revealed MIC values of 2, 16, 0.25, 0.0625, 0.125, 0.25, and 4 μg/mL, respectively, and minimum effective concentration for caspofungin was 0.031 μg/mL. Despite receiving antibacterial and antifungal therapies, the patient unfortunately expired due to bradycardia and hypoxemia. Proper identification and epidemiological surveillance studies are needed to understand the exact prevalence of these emerging yeast pathogens. Previously reported cases of C. palmioleophila infection, primarily associated with bloodstream infections and catheter-related candidemia, were reviewed.
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Affiliation(s)
- Shima Aboutalebian
- Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Nikmanesh
- Department of Medical Laboratory Science, School of Allied Medical Science, Tehran University of Medical Science, Tehran, Iran
- Zoonoses Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Pediatric Intensive Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezoo Charsizadeh
- Immunology, Asthma, and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Mirhendi
- Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
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Erami M, Aboutalebian S, Hashemi Hezaveh SJ, Matini AH, Momen-Heravi M, Ahsaniarani AH, Arani SS, Ganjizadeh M, Mirhendi H. Invasive Fusarium rhinosinusitis in COVID-19 patients: report of three cases with successful management. Front Cell Infect Microbiol 2023; 13:1247491. [PMID: 37780844 PMCID: PMC10538539 DOI: 10.3389/fcimb.2023.1247491] [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: 06/26/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Invasive fungal rhinosinusitis (IFRS) is a life-threatening infection that can occur in immunocompromised patients, including those with COVID-19. Although Mucorales and Aspergillus species are the most common causes of IFRS, infections caused by other fungi such as Fusarium are rare. In this report, we present three cases of proven rhinosinusitis fusariosis that occurred during or after COVID-19 infection. The diagnosis was confirmed through microscopy, pathology, and culture, and species identification of the isolates was performed by DNA sequencing the entire ITS1-5.8 rRNA-ITS2 region and translation elongation factor 1-alpha (TEF-1α). Antifungal susceptibility testing was conducted according to CLSI guidelines. The causative agents were identified as Fusarium proliferatum, F. oxysporum + Aspergillus flavus, and F. solani/falciforme. Treatment involved the administration of antifungal medication and endoscopic sinus surgery to remove the affected mucosa, leading to the successful resolution of the infections. However, one patient experienced a recurrence of IFRS caused by A. flavus 15 months later. Early diagnosis and timely medical and surgical treatment are crucial in reducing mortality rates associated with invasive fusariosis. Additionally, the cautious use of corticosteroids in COVID-19 patients is highly recommended.
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Affiliation(s)
- Mahzad Erami
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Jamal Hashemi Hezaveh
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hassan Matini
- Department of Pathology and Histology, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansooreh Momen-Heravi
- Department of Infectious Disease, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Hossein Ahsaniarani
- Department of Otorhinolaryngology, School of Medicine, Matini Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Shirin Shafaee Arani
- Department of Pathology and Histology, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohsen Ganjizadeh
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Mirhendi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
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Jabrodini A, Sohrabizdeh M, Aboutalebian S, Hashemi SB, Zomorodian K, Alirezaie A, Rasti Jahromi M, Shamsdin SN, Motamedi M. Molecular strategy for the direct detection and identification of the most common fungal community in cerumen specimens by multiplex PCR. J Med Microbiol 2023; 72. [PMID: 37624031 DOI: 10.1099/jmm.0.001746] [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] [Indexed: 08/26/2023] Open
Abstract
Introduction. Otomycosis is a superficial fungal infection that is responsible for approximately 9-27 % of otitis externa. However, fungal communities in otomycosis are varied, but Aspergillus spp. and Candida spp. are the most common causes of this infection.Hypothesis Statement. The multiplex PCR assay is postulated to be able to directly detect more than one fungal genus in cerumen specimens.Aim. This study aimed to develop and evaluate the role of the multiplex PCR assay in detecting the most common genus of fungi that cause otomycosis directly from the cerumen specimens.Methodology. To detect Candida and Aspergillus/Penicillium genera, three pairs of primers, including pan-fungal, pan-Candida, and pan-Aspergillus/Penicillium, were used in a multiplex PCR. In order to evaluate the performance and reproducibility of the multiplex PCR. the cerumen of 140 patients suspected of otomycosis were investigated.Results. Pan-Candida and pan-Aspergillus/Penicillium primers were designed to amplify the ITS1-5.8S-ITS2 region and the β-tubulin gene, respectively. In the multiplex PCR assay, 64 (47.40 %) and 118 (87.40 %) specimens were positive with pan-Candida and pan-Aspergillus/Penicillium primers, respectively. Double amplicon bands of Candida and Aspergillus were obtained in 51 (37.77 %) specimens. In the culture method, yeast (n=18, 13.33 %) and mould (n=117, 86.66 %) were isolated from 135 cerumen specimens. The sensitivity, specificity, and positive and negative predictive values of the multiplex PCR assays using culture method results as the gold standard were determined to be 94, 33, 97, and 22 %, respectively.Conclusion. In our study, multiplex PCR assays enabled simultaneous detection of two common genera of the causative agent of otomycosis in a cerumen specimen. Regarding the high sensitivity of the first step of the multiplex PCR assay, this assay may be used for the direct detection of Candida and Aspergillus genera in other clinical specimens.
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Affiliation(s)
- Ahmad Jabrodini
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Sohrabizdeh
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Basir Hashemi
- Otolaryngology Research Center, Department of Otolaryngology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arefeh Alirezaie
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mona Rasti Jahromi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyedeh Neda Shamsdin
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marjan Motamedi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Aboutalebian S, Charsizadeh A, Eshaghi H, Nikmaesh B, Mirhendi H. A case of Candida metapsilosis conjunctivitis in a neonate admitted to the cardiac heart intensive care unit. Clin Case Rep 2023; 11:e6870. [PMID: 36703771 PMCID: PMC9869643 DOI: 10.1002/ccr3.6870] [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: 06/16/2022] [Revised: 12/12/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023] Open
Abstract
Harmless commensal Candida species, especially uncommon and rare ones may rarely cause a serious infection. Candida metapsilosis is a recently described yeast that is phenotypically indistinguishable from Candida parapsilosis and molecular methods are essential for its identification. We report the first case of Candida conjunctivitis due to C. metapsilosis obtained from the eye discharge of a 40-day-old girl with congenital heart disease admitted to the cardiac intensive care unit (CICU). The yeast isolate was identified by sequencing the entire ITS1-5.8 rRNA-ITS2 region. Antifungal susceptibility testing performed according to the CLSI M27-A3 showed that the isolate was susceptible to amphotericin B, fluconazole, itraconazole, voriconazole, clotrimazole, nystatin, terbinafine, 5-fluorocytosine, and caspofungin. Differentiation of the fungal new species allows us the accurate diagnosis and treatment, and a better understanding the microbial epidemiology.
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Affiliation(s)
- Shima Aboutalebian
- Department of Parasitology and Mycology, School of MedicineIsfahan University of Medical SciencesIsfahanIran,Mycology Reference Laboratory, Research Core Facilities LaboratoryIsfahan University of Medical SciencesIsfahanIran
| | - Arezoo Charsizadeh
- Immunology, Asthma, and Allergy Research InstituteTehran University of Medical SciencesTehranIran
| | - Hamid Eshaghi
- Department of Infectious DiseaseTehran University of Medical SciencesTehranIran
| | - Bahram Nikmaesh
- Department of Medical Laboratory ScienceSchool of Allied Medical Science, Tehran University of Medical ScienceTehranIran,Zoonoses Research CentreTehran University of Medical SciencesTehranIran
| | - Hossein Mirhendi
- Department of Parasitology and Mycology, School of MedicineIsfahan University of Medical SciencesIsfahanIran,Mycology Reference Laboratory, Research Core Facilities LaboratoryIsfahan University of Medical SciencesIsfahanIran
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Babamahmoodi F, Rezai MS, Ahangarkani F, Mohammadi Kali A, Alizadeh-Navaei R, Alishahi A, Najafi N, Haddadi A, Davoudi A, Azargon L, Daftarian Z, Kordi S, Abbasi K. Multiple Candida strains causing oral infection in COVID-19 patients under corticosteroids and antibiotic therapy: An observational study. Front Cell Infect Microbiol 2022; 12:1103226. [PMID: 36619762 PMCID: PMC9816329 DOI: 10.3389/fcimb.2022.1103226] [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: 11/20/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction The occurrence of oral candidiasis (OC) is expected in patients with COVID-19, especially those with moderate to severe forms of infection who are hospitalized and may be on long-term use of broad-spectrum antibiotics or prolonged corticosteroid therapy. We aimed to characterize clinical conditions, the prevalence profile of Candida species, and outcomes of COVID-19 patients with OC. Methods In this observational study, oral samples were obtained from COVID-19 patients suspected of OC admitted to Razi teaching hospital. Patients with OC were monitored daily until discharge from the hospital. Species identification was performed by a two-step multiplex assay named YEAST PLEX, which identifies 17 clinically important uncommon to common yeast strains. Results Among the 4133 patients admitted with COVID-19, 120 (2.90%) suffered from OC. The onset of signs and symptoms of OC in patients was, on average (2.92 ± 3.596 days) with a range (of 1-29 days). The most common OC presentation was white or yellow macules on the buccal surface or the tongue. In (39.16%) of patients suffering from OC multiple Candida strains (with two or more Candida spp.) were identified. The most common Candida species were C. albicans (60.57%), followed by C. glabrata (17.14%), C. tropicalis (11.42%), C. kefyr (10.83%) and C. krusei (3.42%). Notably, OC caused by multiple Candida strains was more predominant in patients under corticosteroid therapy (P <0.0001), broad-spectrum antibiotics therapy (P = 0.028), and those who used nasal corticosteroid spray (P <0.0001). The majority of patients who recovered from OC at the time of discharge were patients with OC by single Candida species (P = 0.049). Discussion Use of corticosteroids and antimicrobial therapy in COVID-19 patients increases risk of OC by multiple Candida strains.
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Affiliation(s)
- Farhang Babamahmoodi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Sadegh Rezai
- Pediatric Infectious Diseases Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Ahangarkani
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,*Correspondence: Fatemeh Ahangarkani,
| | - Ali Mohammadi Kali
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Alizadeh-Navaei
- Gastrointestinal Cancer Research Center, Non-communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbas Alishahi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,Research Committee, Mazandaran University of Medical Sciences, Sari, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Narges Najafi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Azam Haddadi
- Department of Endodontics, Faculty of Dentistry, Dental Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Davoudi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Leila Azargon
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zahra Daftarian
- Northbay Medical Center, Vacaville Center for Primary Care, Vacaville, CA, United States
| | - Shirafkan Kordi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Kiana Abbasi
- Department of Microbiology, Zanjan Branch, Islamic Azad University, Zanjan, Iran
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