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Scoffone VC, Barbieri G, Irudal S, Trespidi G, Buroni S. New Antimicrobial Strategies to Treat Multi-Drug Resistant Infections Caused by Gram-Negatives in Cystic Fibrosis. Antibiotics (Basel) 2024; 13:71. [PMID: 38247630 PMCID: PMC10812592 DOI: 10.3390/antibiotics13010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
People with cystic fibrosis (CF) suffer from recurrent bacterial infections which induce inflammation, lung tissue damage and failure of the respiratory system. Prolonged exposure to combinatorial antibiotic therapies triggers the appearance of multi-drug resistant (MDR) bacteria. The development of alternative antimicrobial strategies may provide a way to mitigate antimicrobial resistance. Here we discuss different alternative approaches to the use of classic antibiotics: anti-virulence and anti-biofilm compounds which exert a low selective pressure; phage therapies that represent an alternative strategy with a high therapeutic potential; new methods helping antibiotics activity such as adjuvants; and antimicrobial peptides and nanoparticle formulations. Their mechanisms and in vitro and in vivo efficacy are described, in order to figure out a complete landscape of new alternative approaches to fight MDR Gram-negative CF pathogens.
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Affiliation(s)
| | | | | | | | - Silvia Buroni
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (V.C.S.); (G.B.); (S.I.); (G.T.)
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Cafaro V, Bosso A, Di Nardo I, D’Amato A, Izzo I, De Riccardis F, Siepi M, Culurciello R, D’Urzo N, Chiarot E, Torre A, Pizzo E, Merola M, Notomista E. The Antimicrobial, Antibiofilm and Anti-Inflammatory Activities of P13#1, a Cathelicidin-like Achiral Peptoid. Pharmaceuticals (Basel) 2023; 16:1386. [PMID: 37895857 PMCID: PMC10610514 DOI: 10.3390/ph16101386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Cationic antimicrobial peptides (CAMPs) are powerful molecules with antimicrobial, antibiofilm and endotoxin-scavenging activities. These properties make CAMPs very attractive drugs in the face of the rapid increase in multidrug-resistant (MDR) pathogens, but they are limited by their susceptibility to proteolytic degradation. An intriguing solution to this issue could be the development of functional mimics of CAMPs with structures that enable the evasion of proteases. Peptoids (N-substituted glycine oligomers) are an important class of peptidomimetics with interesting benefits: easy synthetic access, intrinsic proteolytic stability and promising bioactivities. Here, we report the characterization of P13#1, a 13-residue peptoid specifically designed to mimic cathelicidins, the best-known and most widespread family of CAMPs. P13#1 showed all the biological activities typically associated with cathelicidins: bactericidal activity over a wide spectrum of strains, including several ESKAPE pathogens; the ability to act in combination with different classes of conventional antibiotics; antibiofilm activity against preformed biofilms of Pseudomonas aeruginosa, comparable to that of human cathelicidin LL-37; limited toxicity; and an ability to inhibit LPS-induced proinflammatory effects which is comparable to that of "the last resource" antibiotic colistin. We further studied the interaction of P13#1 with SDS, LPSs and bacterial cells by using a fluorescent version of P13#1. Finally, in a subcutaneous infection mouse model, it showed antimicrobial and anti-inflammatory activities comparable to ampicillin and gentamicin without apparent toxicity. The collected data indicate that P13#1 is an excellent candidate for the formulation of new antimicrobial therapies.
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Affiliation(s)
- Valeria Cafaro
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Andrea Bosso
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Ilaria Di Nardo
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Assunta D’Amato
- Department of Chemistry and Biology “A. Zambelli”, University of Salerno, 84084 Fisciano, Italy; (A.D.); (I.I.); (F.D.R.)
| | - Irene Izzo
- Department of Chemistry and Biology “A. Zambelli”, University of Salerno, 84084 Fisciano, Italy; (A.D.); (I.I.); (F.D.R.)
| | - Francesco De Riccardis
- Department of Chemistry and Biology “A. Zambelli”, University of Salerno, 84084 Fisciano, Italy; (A.D.); (I.I.); (F.D.R.)
| | - Marialuisa Siepi
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Rosanna Culurciello
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Nunzia D’Urzo
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | | | | | - Elio Pizzo
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Marcello Merola
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
| | - Eugenio Notomista
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy; (V.C.); (A.B.); (I.D.N.); (M.S.); (R.C.); (N.D.); (E.P.)
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Cresti L, Cappello G, Vailati S, Melloni E, Brunetti J, Falciani C, Bracci L, Pini A. In Vivo Efficacy and Toxicity of an Antimicrobial Peptide in a Model of Endotoxin-Induced Pulmonary Inflammation. Int J Mol Sci 2023; 24:ijms24097967. [PMID: 37175674 PMCID: PMC10178222 DOI: 10.3390/ijms24097967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023] Open
Abstract
SET-M33 is a synthetic peptide that is being developed as a new antibiotic against major Gram-negative bacteria. Here we report two in vivo studies to assess the toxicity and efficacy of the peptide in a murine model of pulmonary inflammation. First, we present the toxicity study in which SET-M33 was administered to CD-1 mice by snout inhalation exposure for 1 h/day for 7 days at doses of 5 and 20 mg/kg/day. The results showed adverse clinical signs and effects on body weight at the higher dose, as well as some treatment-related histopathology findings (lungs and bronchi, nose/turbinates, larynx and tracheal bifurcation). On this basis, the no observable adverse effect level (NOAEL) was considered to be 5 mg/kg/day. We then report an efficacy study of the peptide in an endotoxin (LPS)-induced pulmonary inflammation model. Intratracheal administration of SET-M33 at 0.5, 2 and 5 mg/kg significantly inhibited BAL neutrophil cell counts after an LPS challenge. A significant reduction in pro-inflammatory cytokines, KC, MIP-1α, IP-10, MCP-1 and TNF-α was also recorded after SET-M33 administration.
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Affiliation(s)
- Laura Cresti
- U.O.C. Clinical Pathology, Azienda Ospedaliera Universitaria Senese, Via M. Bracci, 53100 Siena, Italy
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
| | - Giovanni Cappello
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
- SetLance srl, Via Fiorentina 1, 53100 Siena, Italy
| | | | - Elsa Melloni
- Zambon spa, Via A. Meucci 3, 20091 Bresso, Italy
| | - Jlenia Brunetti
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
| | - Chiara Falciani
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
| | - Luisa Bracci
- U.O.C. Clinical Pathology, Azienda Ospedaliera Universitaria Senese, Via M. Bracci, 53100 Siena, Italy
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
| | - Alessandro Pini
- U.O.C. Clinical Pathology, Azienda Ospedaliera Universitaria Senese, Via M. Bracci, 53100 Siena, Italy
- Medical Biotechnology Department, University of Siena, Via A Moro 2, 53100 Siena, Italy
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Cresti L, Conte G, Cappello G, Brunetti J, Falciani C, Bracci L, Quaglia F, Ungaro F, d’Angelo I, Pini A. Inhalable Polymeric Nanoparticles for Pulmonary Delivery of Antimicrobial Peptide SET-M33: Antibacterial Activity and Toxicity In Vitro and In Vivo. Pharmaceutics 2022; 15:pharmaceutics15010003. [PMID: 36678633 PMCID: PMC9863998 DOI: 10.3390/pharmaceutics15010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Development of inhalable formulations for delivering peptides to the conductive airways and shielding their interactions with airway barriers, thus enhancing peptide/bacteria interactions, is an important part of peptide-based drug development for lung applications. Here, we report the construction of a biocompatible nanosystem where the antimicrobial peptide SET-M33 is encapsulated within polymeric nanoparticles of poly(lactide-co-glycolide) (PLGA) conjugated with polyethylene glycol (PEG). This system was conceived for better delivery of the peptide to the lungs by aerosol. The encapsulated peptide showed prolonged antibacterial activity, due to its controlled release, and much lower toxicity than the free molecule. The peptide-based nanosystem killed Pseudomonas aeruginosa in planktonic and sessile forms in a dose-dependent manner, remaining active up to 72 h after application. The encapsulated peptide showed no cytotoxicity when incubated with human bronchial epithelial cells from healthy individuals and from cystic fibrosis patients, unlike the free peptide, which showed an EC50 of about 22 µM. In vivo acute toxicity studies in experimental animals showed that the peptide nanosystem did not cause any appreciable side effects, and confirmed its ability to mitigate the toxic and lethal effects of free SET-M33.
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Affiliation(s)
- Laura Cresti
- Laboratory of Clinical Pathology, Santa Maria alle Scotte University Hospital, 53100 Siena, Italy
- SetLance srl, 53100 Siena, Italy
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Gemma Conte
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy
| | - Giovanni Cappello
- SetLance srl, 53100 Siena, Italy
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Jlenia Brunetti
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Chiara Falciani
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Luisa Bracci
- Laboratory of Clinical Pathology, Santa Maria alle Scotte University Hospital, 53100 Siena, Italy
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Fabiana Quaglia
- Department of Pharmacy, University of Naples Federico II, 80131 Napoli, Italy
| | - Francesca Ungaro
- Department of Pharmacy, University of Naples Federico II, 80131 Napoli, Italy
| | - Ivana d’Angelo
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy
- Correspondence: (I.d.); (A.P.)
| | - Alessandro Pini
- Laboratory of Clinical Pathology, Santa Maria alle Scotte University Hospital, 53100 Siena, Italy
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
- Correspondence: (I.d.); (A.P.)
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Cresti L, Falciani C, Cappello G, Brunetti J, Vailati S, Melloni E, Bracci L, Pini A. Safety evaluations of a synthetic antimicrobial peptide administered intravenously in rats and dogs. Sci Rep 2022; 12:19294. [PMID: 36369523 DOI: 10.1038/s41598-022-23841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022] Open
Abstract
The antimicrobial peptide SET-M33 is under study for the development of a new antibiotic against major Gram-negative pathogens. Here we report the toxicological evaluation of SET-M33 administered intravenously to rats and dogs. Dose range finding experiments determined the doses to use in toxicokinetic evaluation, clinical biochemistry analysis, necroscopy and in neurological and respiratory measurements. Clinical laboratory investigations in dogs and rats showed a dose-related increase in creatinine and urea levels, indicating that the kidneys are the target organ. This was also confirmed by necroscopy studies of animal tissues, where signs of degeneration and regeneration were found in kidney when SET-M33 was administered at the highest doses in the two animal species. Neurological toxicity measurements by the Irwin method and respiratory function evaluation in rats did not reveal any toxic effect even at the highest dose. Finally, repeated administration of SET-M33 by short infusion in dogs revealed a no-observed-adverse-effect-level of 0.5 mg/kg/day.
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Wang Y, Chang RYK, Britton WJ, Chan HK. Advances in the development of antimicrobial peptides and proteins for inhaled therapy. Adv Drug Deliv Rev 2022; 180:114066. [PMID: 34813794 DOI: 10.1016/j.addr.2021.114066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022]
Abstract
Antimicrobial peptides and proteins (APPs) are becoming increasingly important in targeting multidrug-resistant (MDR) bacteria. APPs is a rapidly emerging area with novel molecules being produced and further optimised to enhance antimicrobial efficacy, while overcoming issues associated with biologics such as potential toxicity and low bioavailability resulting from short half-life. Inhalation delivery of these agents can be an effective treatment of respiratory infections owing to the high local drug concentration in the lungs with lower exposure to systemic circulation hence reducing systemic toxicity. This review describes the recent studies on inhaled APPs, including in vitro and in vivo antimicrobial activities, toxicity assessments, and formulation strategies whenever available. The review also includes studies on combination of APPs with other antimicrobial agents to achieve enhanced synergistic antimicrobial effect. Since different APPs have different biological and chemical stabilities, a targeted formulation strategy should be considered for developing stable and inhalable antimicrobial peptides and proteins. These strategies include the use of sodium chloride to reduce electrostatic interaction between APP and extracellular DNA in sputum, the use of D-enantiomers or dendrimers to minimise protease-mediated degradation and or the use of prodrugs to reduce toxicity. Although great effort has been put towards optimising the biological functions of APPs, studies assessing biological stability in inhalable aerosols are scarce, particularly for novel molecules. As such, formulation and manufacture of inhalable liquid and powder formulations of APPs are underexplored, yet they are crucial areas of research for clinical translation.
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de Souza CM, da Silva ÁP, Júnior NGO, Martínez OF, Franco OL. Peptides as a therapeutic strategy against Klebsiella pneumoniae. Trends Pharmacol Sci 2022; 43:335-348. [DOI: 10.1016/j.tips.2021.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 12/26/2022]
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Ferrera L, Cappiello F, Loffredo MR, Puglisi E, Casciaro B, Botta B, Galietta LJV, Mori M, Mangoni ML. Esc peptides as novel potentiators of defective cystic fibrosis transmembrane conductance regulator: an unprecedented property of antimicrobial peptides. Cell Mol Life Sci 2021. [PMID: 34971429 DOI: 10.1007/s00018-021-04030-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 12/17/2022]
Abstract
Mutations in the cystic fibrosis (CF) transmembrane conductance regulator (CFTR) protein lead to persistent lung bacterial infections, mainly due to Pseudomonas aeruginosa, causing loss of respiratory function and finally death of people affected by CF. Unfortunately, even in the era of CFTR modulation therapies, management of pulmonary infections in CF remains highly challenging especially for patients with advanced stages of lung disease. Recently, we identified antimicrobial peptides (AMPs), namely Esc peptides, with potent antipseudomonal activity. In this study, by means of electrophysiological techniques and computational studies we discovered their ability to increase the CFTR-controlled ion currents, by direct interaction with the F508del-CFTR mutant. Remarkably, this property was not explored previously with any AMPs or peptides in general. More interestingly, in contrast with clinically used CFTR modulators, Esc peptides would give particular benefit to CF patients by combining their capability to eradicate lung infections and to act as promoters of airway wound repair with their ability to ameliorate the activity of the channel with conductance defects. Overall, our findings not only highlighted Esc peptides as the first characterized AMPs with a novel property, that is the potentiator activity of CFTR, but also paved the avenue to investigate the functions of AMPs and/or other peptide molecules, for a new up-and-coming pharmacological approach to address CF lung disease.
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Brunetti J, Carnicelli V, Ponzi A, Di Giulio A, Lizzi AR, Cristiano L, Cresti L, Cappello G, Pollini S, Mosconi L, Rossolini GM, Bracci L, Falciani C, Pini A. Antibacterial and Anti-Inflammatory Activity of an Antimicrobial Peptide Synthesized with D Amino Acids. Antibiotics (Basel) 2020; 9:antibiotics9120840. [PMID: 33255172 PMCID: PMC7760307 DOI: 10.3390/antibiotics9120840] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 12/13/2022] Open
Abstract
The peptide SET-M33 is a molecule synthesized in tetra-branched form which is being developed as a new antibiotic against Gram-negative bacteria. Its isomeric form with D amino acids instead of the L version (SET-M33D) is also able to kill Gram-positive bacteria because of its higher resistance to bacterial proteases (Falciani et al., PLoS ONE, 2012, 7, e46259). Here we report the strong in vitro activity of SET-M33D (MIC range 0.7-6.0 µM) against multiresistant pathogens of clinical interest, including Gram-positives Staphylococcus aureus, Staphylococcus saprophyticus, and Enterococcus faecalis, and various Gram-negative enterobacteriaceae. SET-M33D antibacterial activity is also confirmed in vivo against a MRSA strain of S. aureus with doses perfectly compatible with clinical use (5 and 2.5 mg/Kg). Moreover, SET-M33D strongly neutralized lipopolysaccharide (LPS) and lipoteichoic acid (LTA), thus exerting a strong anti-inflammatory effect, reducing expression of cytokines, enzymes, and transcription factors (TNF-α, IL6, COX-2, KC, MIP-1, IP10, iNOS, NF-κB) involved in the onset and evolution of the inflammatory process. These results, along with in vitro and in vivo toxicity data and the low frequency of resistance selection reported here, make SET-M33D a strong candidate for the development of a new broad spectrum antibiotic.
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Affiliation(s)
- Jlenia Brunetti
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.C.); (L.B.); (C.F.); (A.P.)
- Correspondence:
| | - Veronica Carnicelli
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (V.C.); (A.P.); (A.D.G.); (A.R.L.)
| | - Alessia Ponzi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (V.C.); (A.P.); (A.D.G.); (A.R.L.)
| | - Antonio Di Giulio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (V.C.); (A.P.); (A.D.G.); (A.R.L.)
| | - Anna Rita Lizzi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (V.C.); (A.P.); (A.D.G.); (A.R.L.)
| | - Loredana Cristiano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Laura Cresti
- SetLance srl, Toscana Life Sciences, 53100 Siena, Italy;
| | - Giovanni Cappello
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.C.); (L.B.); (C.F.); (A.P.)
| | - Simona Pollini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy; (S.P.); (L.M.); (G.M.R.)
- Microbiology and Virology Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Lara Mosconi
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy; (S.P.); (L.M.); (G.M.R.)
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy; (S.P.); (L.M.); (G.M.R.)
- Microbiology and Virology Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Luisa Bracci
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.C.); (L.B.); (C.F.); (A.P.)
- Laboratory of Clinical Pathology, Santa Maria alle Scotte Hospital, 53100 Siena, Italy
| | - Chiara Falciani
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.C.); (L.B.); (C.F.); (A.P.)
| | - Alessandro Pini
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.C.); (L.B.); (C.F.); (A.P.)
- Laboratory of Clinical Pathology, Santa Maria alle Scotte Hospital, 53100 Siena, Italy
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