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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 DOI: 10.1128/cmr.00104-23] [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: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Mermel LA, Rupp ME. Should Blood Cultures Be Drawn Through an Indwelling Catheter? Open Forum Infect Dis 2024; 11:ofae248. [PMID: 38770214 PMCID: PMC11103617 DOI: 10.1093/ofid/ofae248] [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: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
There is no practical way to definitively diagnose a catheter-related bloodstream infection in situ if blood cultures are only obtained percutaneously unless there is the rare occurrence of purulent drainage from a central venous catheter insertion site. That is why the Infectious Diseases Society of America guidelines for diagnosis and management of catheter-related bloodstream infections and Infectious Diseases Society of America guidelines for evaluation of fever in critically ill patients both recommend drawing blood cultures from a central venous catheter and percutaneously if the catheter is a suspected source of infection. However, central venous catheter-drawn blood cultures may be more likely to be positive reflecting catheter hub, connector, or intraluminal colonization, and many hospitals in the United States discourage blood culture collection from catheters in an effort to reduce reporting of central-line associated bloodstream infections to the Centers for Disease Control and Prevention. As such, clinical decisions are made regarding catheter removal or other therapeutic interventions based on incomplete and potentially inaccurate data. We urge clinicians to obtain catheter-drawn blood cultures when the catheter may be the source of suspected infection.
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Affiliation(s)
- Leonard A Mermel
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Epidemiology and Infection Prevention, Lifespan Hospital System, Providence, Rhode Island, USA
| | - Mark E Rupp
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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3
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O'Grady NP, Alexander E, Alhazzani W, Alshamsi F, Cuellar-Rodriguez J, Jefferson BK, Kalil AC, Pastores SM, Patel R, van Duin D, Weber DJ, Deresinski S. Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Crit Care Med 2023; 51:1570-1586. [PMID: 37902340 DOI: 10.1097/ccm.0000000000006022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
RATIONALE Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation. OBJECTIVES This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. PANEL DESIGN The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline. METHODS We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements. RESULTS The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data. CONCLUSIONS The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.
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Affiliation(s)
- Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health Clinical Center, Bethesda, MD
| | - Earnest Alexander
- Clinical Pharmacy Services, Department of Pharmacy, Tampa General Hospital, Tampa, FL
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Jennifer Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, Bethesda, MD
| | - Brian K Jefferson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Internal Medicine-Critical Care Services, Atrium Health Cabarrus, Concord, NC
| | - Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Rochester, MN
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - David J Weber
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - Stanley Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA
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Dhaliwal M, Daneman N. Utility of Differential Time to Positivity in Diagnosing Central Line-Associated Bloodstream Infections: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 77:428-437. [PMID: 37062596 DOI: 10.1093/cid/ciad225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Differential time to positivity (DTP), defined as pathogen growth at least 2 hours earlier from catheter versus paired peripheral blood cultures, is sometimes used to diagnose central line-associated bloodstream infections (CLABSIs). Previous studies assessing DTP, however, have been small, provided conflicting results, and did not assess heterogeneity across important subgroups. METHODS We systematically reviewed the diagnostic characteristics of DTP for CLABSI using MEDLINE, Embase, WoS, CINAHL, LILACS, AMED, and the Cochrane database. Studies were included if they reported sensitivities, specificities, predictive values, likelihood ratios, or 2 × 2 tables of DTP for diagnosing CLABSI. Extracted data were analyzed by using forest plots, bivariate model meta-analysis, and QUADAS-2 quality assessment. RESULTS We identified 274 records, of which 23 met the criteria for meta-analysis. Among 2526 suspected CLABSIs, DTP demonstrated a summary sensitivity of 81.3% (95% confidence interval [CI]: 72.8%-87.7%), specificity of 91.8% (95% CI: 84.5%-95.8%), positive likelihood ratio of 9.89 (95% CI: 5.14-19.00), and negative likelihood ratio of 0.20 (95% CI: .14-.30). Covariate analysis based on catheter duration, study design, and patient immune status demonstrated no significant differences. However, DTP performed worse for Staphylococcus aureus (low sensitivity but high specificity) and Candida (high sensitivity but low specificity) compared to other organisms. CONCLUSIONS DTP performs well in ruling CLABSIs in or out. Obtaining paired catheter and peripheral blood cultures for DTP when the infectious source is unclear may prevent unnecessary line removal and diagnostic tests. However, this must be balanced against higher contamination rates from catheter cultures.
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Affiliation(s)
- Manreet Dhaliwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Nakayama I, Izawa J, Gibo K, Murakami S, Akiyama T, Kotani Y, Katsurai R, Kishihara Y, Tsuchida T, Takakura S, Takayama Y, Narita M, Shiiki S. Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study. Chest 2023; 164:90-100. [PMID: 36731787 DOI: 10.1016/j.chest.2023.01.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/05/2023] [Accepted: 01/18/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive. RESEARCH QUESTION Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection? STUDY DESIGN AND METHODS In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%. RESULTS Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001). INTERPRETATION Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients. CLINICAL TRIAL REGISTRATION University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/.
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Affiliation(s)
- Izumi Nakayama
- Division of Intensive Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan; Department of Public Health, School of Medicine, Yokohama City University, Yokohama, Japan; Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan.
| | - Junichi Izawa
- Division of Intensive Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan; Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Koichiro Gibo
- Department of Emergency Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan; Department of Home Care Medicine, Nishizaki Hospital, Itoman, Japan
| | - Sara Murakami
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai, Japan
| | - Taisuke Akiyama
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Rie Katsurai
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kishihara
- Emergency and Critical Care Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Takahiro Tsuchida
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunichi Takakura
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | - Yoshihiro Takayama
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | - Masashi Narita
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan; Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Nanbu Medical Center and Children's Medical Center, Haebaru, Japan
| | - Soichi Shiiki
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
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Orozco-Santana E, Fowlds T, Tamayo M, Jew C, Young P, Sheehan P, Murray K, Marcarian T. Reducing CLABSIs in an Adult Cardiothoracic ICU. Am J Nurs 2023; 123:43-49. [PMID: 37077018 DOI: 10.1097/01.naj.0000933940.28749.68] [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: 04/21/2023]
Abstract
LOCAL PROBLEM Central line-associated bloodstream infections (CLABSIs) are associated with increased mortality and costs. In the cardiothoracic ICU (CTICU) of an academic medical center, nine CLABSIs occurred in fiscal year (FY) 2018. PURPOSE The aim of this project was to reduce the CLABSI rate in the CTICU and sustain the results. METHODS Nurse residents on the CTICU initiated a quality improvement project with a single intervention and expanded it into an ongoing initiative with additional interventions by the unit-based performance improvement committee. Evidence-based interventions were identified and implemented, including education; rounding; auditing; and other unit-specific interventions, which included "Central Line Sunday," accountability emails, and a blood culture algorithm with a tip sheet. RESULTS CLABSI incidence was reduced from nine in FY 2018 to one in each of the subsequent FYs (2019 and 2020), which had similar totals of central line days, and two in FY 2021, which had a slightly higher number of central line days. The CTICU was able to achieve zero CLABSIs from August 2019 through November 2020, more than 365 days. CONCLUSIONS Coupled with strong support from nursing leadership, nurses on the unit successfully reduced CLABSIs by adopting novel, evidence-based strategies; ongoing monitoring; and multiple interventions.
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Affiliation(s)
- Emmanuel Orozco-Santana
- Emmanuel Orozco-Santana , Taryn Fowlds , Michelle Tamayo , Christine Jew , and Patricia Young are clinical nurses II, Patty Sheehan is a cardiac clinical nurse specialist, Katrine Murray is the unit director, and Taline Marcarian is a clinical nurse III, all in the cardiothoracic ICU at Ronald Reagan UCLA Medical Center in Los Angeles. Contact author: Taline Marcarian, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Kovoor E, Kobayashi T, Sheeler LL, Trannel A, Etienne W, Abosi O, Holley S, Dains A, Jenn KE, Meacham H, Hanna B, Marra AR, Parsons M, Ford B, Wellington M, Diekema DJ, Salinas JL. Blood culture practices in patients with a central line at an academic medical center-Iowa, 2020. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e64. [PMID: 36483395 PMCID: PMC9726581 DOI: 10.1017/ash.2022.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 06/17/2023]
Abstract
We analyzed blood-culture practices to characterize the utilization of the Infectious Diseases Society of America (IDSA) recommendations related to catheter-related bloodstream infection (CRBSI) blood cultures. Most patients with a central line had only peripheral blood cultures. Increasing the utilization of CRBSI guidelines may improve clinical care, but may also affect other quality metrics.
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Affiliation(s)
- Elias Kovoor
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Takaaki Kobayashi
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | | | - Alexandra Trannel
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - William Etienne
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Oluchi Abosi
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Stephanie Holley
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Angelique Dains
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Kyle E. Jenn
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Holly Meacham
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Beth Hanna
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Alexandre R. Marra
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Meredith Parsons
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Bradley Ford
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | | | - Daniel J. Diekema
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
| | - Jorge L. Salinas
- University of Iowa Hospitals & Clinics, Iowa City, Iowa, United States
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Doern GV, Carroll KC, Diekema DJ, Garey KW, Rupp ME, Weinstein MP, Sexton DJ. Practical Guidance for Clinical Microbiology Laboratories: A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem. Clin Microbiol Rev 2019; 33:e00009-19. [PMID: 31666280 PMCID: PMC6822992 DOI: 10.1128/cmr.00009-19] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In this review, we present a comprehensive discussion of matters related to the problem of blood culture contamination. Issues addressed include the scope and magnitude of the problem, the bacteria most often recognized as contaminants, the impact of blood culture contamination on clinical microbiology laboratory function, the economic and clinical ramifications of contamination, and, perhaps most importantly, a systematic discussion of solutions to the problem. We conclude by providing a series of unanswered questions that pertain to this important issue.
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Affiliation(s)
- Gary V Doern
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karen C Carroll
- Division of Medical Microbiology, Department of Pathology, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Diekema
- Division of Infectious Diseases, Department of Medicine and Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mark E Rupp
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melvin P Weinstein
- Department of Pathology and Laboratory Medicine, Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Daniel J Sexton
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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