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Luo X, Han S, Wang Y, Du P, Li X, Thai PK. Significant differences in usage of antibiotics in three Chinese cities measured by wastewater-based epidemiology. Water Res 2024; 254:121335. [PMID: 38417269 DOI: 10.1016/j.watres.2024.121335] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/08/2024] [Accepted: 02/17/2024] [Indexed: 03/01/2024]
Abstract
Antibiotic use, particularly inappropriate use by irrational prescribing or over-the-counter purchases, is of great concern for China as it facilitates the spread of antibiotic resistances. In this study, we applied wastewater-based epidemiology (WBE) to monitor the total consumption of eight common antibiotics in three cities in northern, eastern and southern China. Wastewater samples were successively collected from 17 wastewater treatment plants including weekdays and weekends spanning four seasons between 2019 and 2021. The concentration of antibiotics and their corresponding metabolites showed a significant correlation, confirming the measured antibiotics were actually consumed. Different seasonal trends in antibiotic use were found among the cities. It was more prevalent in the winter in the northern city Beijing, with the high antibiotic consumption attributed to peak influenza occurrence in the city. This is clear evidence of irrational prescription of antibiotics since it's known that antibiotics do little to treat influenza. In terms of overall consumption, Foshan is significantly lower, thanks to warmer climate and higher use of herbal tea as a prevention measure. WBE estimates of antibiotic consumption were relatively comparable with other data sources, with azithromycin as the top antibiotic measured here. The studied cities had higher WBE estimated antibiotics consumption than results of previous studies in the literature. Monitoring antibiotic use in different areas and periods through WBE in combination with complementary information, can better inform appropriate antibiotic guideline policies in various regions and nations.
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Affiliation(s)
- Xiaozhe Luo
- Laboratory for Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, Beijing 100871, PR China
| | - Sheng Han
- Fujian Water Resource Investment and Development Group Co., Ltd., 350001, Fuzhou, China
| | - Yue Wang
- Laboratory for Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, Beijing 100871, PR China
| | - Peng Du
- Beijing Key Laboratory of Urban Hydrological Cycle and Sponge City Technology, College of Water Sciences, Beijing Normal University, Beijing 100875, PR China.
| | - Xiqing Li
- Laboratory for Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, Beijing 100871, PR China
| | - Phong K Thai
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Brisbane, Queensland 4102, Australia
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2
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Tiwari A, Krolicka A, Tran TT, Räisänen K, Ásmundsdóttir ÁM, Wikmark OG, Lood R, Pitkänen T. Antibiotic resistance monitoring in wastewater in the Nordic countries: A systematic review. Environ Res 2024; 246:118052. [PMID: 38163547 DOI: 10.1016/j.envres.2023.118052] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/23/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
The Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) have effectively kept lower antibiotic-resistant bacterial (ARB) pathogen rates than many other countries. However, in recent years, these five countries have encountered a rise in ARB cases and challenges in treating infections due to the growing prevalence of ARB pathogens. Wastewater-based surveillance (WBS) is a valuable supplement to clinical methods for ARB surveillance, but there is a lack of comprehensive understanding of WBS application for ARB in the Nordic countries. This review aims to compile the latest state-of-the-art developments in WBS for ARB monitoring in the Nordic countries and compare them with clinical surveillance practices. After reviewing 1480 papers from the primary search, 54 were found relevant, and 15 additional WBS-related papers were included. Among 69 studies analyzed, 42 dedicated clinical epidemiology, while 27 focused on wastewater monitoring. The PRISMA review of the literature revealed that Nordic countries focus on four major WBS objectives of ARB: assessing ARB in the human population, identifying ARB evading wastewater treatment, quantifying removal rates, and evaluating potential ARB evolution during the treatment process. In both clinical and wastewater contexts, the most studied targets were pathogens producing carbapenemase and extended-spectrum beta-lactamase (ESBL), primarily Escherichia coli and Klebsiella spp. However, vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) have received more attention in clinical epidemiology than in wastewater studies, probably due to their lower detection rates in wastewater. Clinical surveillance has mostly used culturing, antibiotic susceptibility testing, and genotyping, but WBS employed PCR-based and metagenomics alongside culture-based techniques. Imported cases resulting from international travel and hospitalization abroad appear to have frequently contributed to the rise in ARB pathogen cases in these countries. The many similarities between the Nordic countries (e.g., knowledge exchange practices, antibiotic usage patterns, and the current ARB landscape) could facilitate collaborative efforts in developing and implementing WBS for ARB in population-level screening.
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Affiliation(s)
- Ananda Tiwari
- Expert Microbiology Unit, Finnish Institute for Health and Welfare, 70701, Kuopio, Finland.
| | - Adriana Krolicka
- Norwegian Research Centre AS (NORCE), Nygårdstangen, 5838, Bergen, Norway
| | - Tam T Tran
- Norwegian Research Centre AS (NORCE), Nygårdstangen, 5838, Bergen, Norway
| | - Kati Räisänen
- Expert Microbiology Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Odd-Gunnar Wikmark
- Norwegian Research Centre AS (NORCE), Nygårdstangen, 5838, Bergen, Norway; Unit for Environmental Science and Management, North West University, Potchefstroom Campus, Private Bag X6001, Potchefstroom 2520, South Africa
| | - Rolf Lood
- Department of Clinical Sciences Lund, Division of Infection Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Tarja Pitkänen
- Expert Microbiology Unit, Finnish Institute for Health and Welfare, 70701, Kuopio, Finland; Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, University of Helsinki, Finland.
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3
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Puljko A, Barišić I, Dekić Rozman S, Križanović S, Babić I, Jelić M, Maravić A, Udiković-Kolić N. Molecular epidemiology and mechanisms of carbapenem and colistin resistance in Klebsiella and other Enterobacterales from treated wastewater in Croatia. Environ Int 2024; 185:108554. [PMID: 38479059 DOI: 10.1016/j.envint.2024.108554] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 03/02/2024] [Indexed: 03/26/2024]
Abstract
Among the most problematic bacteria with clinical relevance are the carbapenem-resistant Enterobacterales (CRE), as there are very limited options for their treatment. Treated wastewater can be a route for the release of these bacteria into the environment and the population. The aim of this study was to isolate CRE from treated wastewater from the Zagreb wastewater treatment plant and to determine their phenotypic and genomic characteristics. A total of 200 suspected CRE were isolated, 148 of which were confirmed as Enterobacterales by MALDI-TOF MS. The predominant species was Klebsiella spp. (n = 47), followed by Citrobacter spp. (n = 40) and Enterobacter cloacae complex (cplx.) (n = 35). All 148 isolates were carbapenemase producers with a multidrug-resistant phenotype. Using multi-locus sequence typing and whole-genome sequencing (WGS), 18 different sequence types were identified among these isolates, 14 of which were associated with human-associated clones. The virulence gene analysis of the sequenced Klebsiella isolates (n = 7) revealed their potential pathogenicity. PCR and WGS showed that the most frequent carbapenemase genes in K. pneumoniae were blaOXA-48 and blaNDM-1, which frequently occurred together, while blaKPC-2 together with blaNDM-1 was mainly detected in K. oxytoca, E. cloacae cplx. and Citrobacter spp. Colistin resistance was observed in 40% of Klebsiella and 57% of Enterobacter isolates. Underlying mechanisms identified by WGS include known and potentially novel intrinsic mechanisms (point mutations in the pmrA/B, phoP/Q, mgrB and crrB genes) and acquired mechanisms (mcr-4.3 gene). The mcr-4.3 gene was identified for the first time in K. pneumoniae and is probably located on the conjugative IncHI1B plasmid. In addition, WGS analysis of 13 isolates revealed various virulence genes and resistance genes to other clinically relevant antibiotics as well as different plasmids possibly associated with carbapenemase genes. Our study demonstrates the important role that treated municipal wastewater plays in harboring and spreading enterobacterial pathogens that are resistant to last-resort antibiotics.
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Affiliation(s)
- Ana Puljko
- Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička 54, P.O. Box 180, 10 002 Zagreb, Croatia
| | - Ivan Barišić
- Molecular Diagnostics, Austrian Institute of Technology, Giefinggasse 4, 1210 Vienna, Austria
| | - Svjetlana Dekić Rozman
- Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička 54, P.O. Box 180, 10 002 Zagreb, Croatia
| | - Stela Križanović
- Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička 54, P.O. Box 180, 10 002 Zagreb, Croatia
| | - Ivana Babić
- Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička 54, P.O. Box 180, 10 002 Zagreb, Croatia
| | - Marko Jelić
- Department of Clinical Microbiology, University Hospital for Infectious Diseases, Mirogojska 8, 10 000 Zagreb, Croatia
| | - Ana Maravić
- Department of Biology, Faculty of Science, University of Split, Ruđera Boškovića 33, 21 000 Split, Croatia
| | - Nikolina Udiković-Kolić
- Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička 54, P.O. Box 180, 10 002 Zagreb, Croatia.
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Sabatino R, Sbaffi T, Corno G, Cabello-Yeves PJ, Di Cesare A. The diversity of the antimicrobial resistome of lake Tanganyika increases with the water depth. Environ Pollut 2024; 342:123065. [PMID: 38043766 DOI: 10.1016/j.envpol.2023.123065] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/05/2023]
Abstract
The presence of antimicrobial resistance genes (ARGs) in the microbiome of freshwater communities is a consequence of thousands of years of evolution but also of the pressure exerted by anthropogenic activities, with potential negative impact on environmental and human health. In this study, we investigated the distribution of ARGs in Lake Tanganyika (LT)'s water column to define the resistome of this ancient lake. Additionally, we compared the resistome of LT with that of Lake Baikal (LB), the oldest known lake with different environmental characteristics and a lower anthropogenic pollution than LT. We found that richness and abundance of several antimicrobial resistance classes were higher in the deep water layers in both lakes. LT Kigoma region, known for its higher anthropogenic pollution, showed a greater richness and number of ARG positive MAGs compared to Mahale. Our results provide a comprehensive understanding of the antimicrobial resistome of LT and underscore its importance as reservoir of antimicrobial resistance. In particular, the deepest water layers of LT are the main repository of diverse ARGs, mirroring what was observed in LB and in other aquatic ecosystems. These findings suggest that the deep waters might play a crucial role in the preservation of ARGs in aquatic ecosystems.
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Affiliation(s)
- Raffaella Sabatino
- National Research Council of Italy - Water Research Institute (CNR-IRSA), Verbania, Italy
| | - Tomasa Sbaffi
- National Research Council of Italy - Water Research Institute (CNR-IRSA), Verbania, Italy
| | - Gianluca Corno
- National Research Council of Italy - Water Research Institute (CNR-IRSA), Verbania, Italy; National Biodiversity Future Center (NBFC), 90133, Palermo, Italy
| | | | - Andrea Di Cesare
- National Research Council of Italy - Water Research Institute (CNR-IRSA), Verbania, Italy; National Biodiversity Future Center (NBFC), 90133, Palermo, Italy.
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5
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Gomi R, Matsumura Y, Yamamoto M, Tanaka M, Komakech AJ, Matsuda T, Harada H. Genomic surveillance of antimicrobial-resistant Escherichia coli in fecal sludge and sewage in Uganda. Water Res 2024; 248:120830. [PMID: 37979567 DOI: 10.1016/j.watres.2023.120830] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/24/2023] [Accepted: 11/03/2023] [Indexed: 11/20/2023]
Abstract
The global increase of antimicrobial resistance (AMR) is a major public health concern. An effective AMR surveillance tool is needed to track the emergence and spread of AMR. Wastewater surveillance has been proposed as a resource-efficient tool for monitoring AMR carriage in the community. Here, we performed genomic surveillance of antimicrobial-resistant Escherichia coli obtained from fecal sludge and sewage in Uganda to gain insights into E. coli epidemiology and AMR burden in the underlying population. Selective media containing different antibiotic combinations (cefotaxime, ciprofloxacin, cefotaxime + ciprofloxacin + gentamicin) were used to obtain antimicrobial-resistant E. coli from fecal sludge and sewage. Short-read sequencing was performed for the obtained isolates, and a subset of isolates (selected from predominant sequence types (STs)) was also subjected to long-read sequencing. Genomic analysis of the obtained E. coli isolates (n = 181) revealed the prevalence of clonal complex 10, including ST167 (n = 43), ST10 (n = 28), ST1284 (n = 17), and ST617 (n = 4), in both fecal sludge and sewage, irrespective of antibiotics used for selection. We also detected global high-risk clones ST1193 (n = 10) and ST131 (n = 2 clade A, n = 3 subclade C1-M27, and n = 1 subclade C2). Diverse AMR determinants, including extended-spectrum β-lactamase genes (mostly blaCTX-M-15) and mutations in gyrA and parC, were identified. Analysis of the completed genomes revealed that diverse IncF plasmids and chromosomal integration were the major contributors to the spread of AMR genes in the predominant STs. This study showed that a combination of sewage surveillance (or fecal sludge surveillance) and whole-genome sequencing can be a powerful tool for monitoring AMR carriage in the underlying population.
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Affiliation(s)
- Ryota Gomi
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Katsura, Nishikyo-ku, Kyoto 615-8540, Japan.
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Masaki Yamamoto
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Mai Tanaka
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Katsura, Nishikyo-ku, Kyoto 615-8540, Japan
| | - Allan John Komakech
- Department of Agricultural and Biosystems Engineering, College of Agricultural and Environmental Sciences, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Tomonari Matsuda
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Katsura, Nishikyo-ku, Kyoto 615-8540, Japan
| | - Hidenori Harada
- Graduate School of Asian and African Area Studies, Kyoto University, Yoshida-Shimoadachi, Sakyo-ku, Kyoto 606-8501, Japan.
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6
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Bauer EM, Talone A, Imperatori P, Briancesco R, Bonadonna L, Carbone M. The Addition of Co into CuO-ZnO Oxides Triggers High Antibacterial Activity and Low Cytotoxicity. Nanomaterials (Basel) 2023; 13:2823. [PMID: 37947668 PMCID: PMC10649786 DOI: 10.3390/nano13212823] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
In the present work, a simple two-step method is proposed for mixed oxide synthesis aimed at the achievement of antibacterial nanomaterials. In particular, Cu, Zn and Co have been selected to achieve single-, double- and triple-cation oxides. The synthesized samples are characterized by XRD, IR, SEM and EDX, indicating the formation of either crystalline or amorphous hydrocarbonate precursors. The oxides present one or two crystalline phases, depending on their composition; the triple-cation oxides form a solid solution of tenorite. Also, the morphology of the samples varies with the composition, yielding nanoparticles, filaments and hydrangea-like microaggregates. The antibacterial assays are conducted against E. coli and indicate an enhanced efficacy, especially displayed by the oxide containing 3% Co and 9% Zn incorporated into the CuO lattice. The oxides with the highest antibacterial properties are tested for their cytotoxicity, indicating a low toxicity impact, in line with literature data.
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Affiliation(s)
- Elvira Maria Bauer
- Institute of Structure of Matter-Italian National Research Council (ISM-CNR), Via Salaria Km 29.3, 00015 Monterotondo, Italy; (E.M.B.); (P.I.)
| | - Alessandro Talone
- Department of Chemical Science and Technologies, University of Rome Tor Vergata, Via della Ricerca Scientifica, 00133 Rome, Italy;
| | - Patrizia Imperatori
- Institute of Structure of Matter-Italian National Research Council (ISM-CNR), Via Salaria Km 29.3, 00015 Monterotondo, Italy; (E.M.B.); (P.I.)
| | - Rossella Briancesco
- National Center for Water Safety, Italian National Health Institute, Viale Regina Elena 299, 00161 Rome, Italy; (R.B.); (L.B.)
| | - Lucia Bonadonna
- National Center for Water Safety, Italian National Health Institute, Viale Regina Elena 299, 00161 Rome, Italy; (R.B.); (L.B.)
| | - Marilena Carbone
- Department of Chemical Science and Technologies, University of Rome Tor Vergata, Via della Ricerca Scientifica, 00133 Rome, Italy;
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Ågerstrand M, Josefsson H, Wernersson AS, Larsson DGJ. Opportunities to tackle antibiotic resistance development in the aquatic environment through the Water Framework Directive. Ambio 2023; 52:941-951. [PMID: 36723847 PMCID: PMC10073357 DOI: 10.1007/s13280-022-01828-7] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/02/2022] [Accepted: 12/29/2022] [Indexed: 06/18/2023]
Abstract
Antibiotics are critical components of modern health care. Protecting their efficacy through managing the rise in antibiotic resistance is therefore a global concern. It is not known to what extent environmental pollution from antibiotics contributes to the development of resistance, but encountered concentrations are frequently above concentrations predicted to select for resistance. Hence, measures are needed to manage risks. Here, we analyse if the indirect health risks from antibiotics in the aquatic environment can be considered in the context of the EU Water Framework Directive and the setting of environmental quality standards (EQS). By scrutinising current legislation, we conclude that it is possible to take the indirect health risks from antimicrobial resistance into account when deriving EQS for substances with antibiotic activity. We base this on the following conclusions: (1) human health concerns can be the main driver when setting an EQS, (2) an EQS can be based on data not specified in the guidance document, and (3) there are no restrictions against establishing EQS using data on antimicrobial resistance properties. In addition, since antimicrobial resistance travel across borders, we see strong reasons to prioritise setting these EQS on the EU level over the national level. Even though there is no agreed-upon method for how to develop EQS protective against resistance selection, there are several suggestions available in the literature and a couple of examples of regulatory initiatives. Also, addressing antimicrobial resistance through the Water Framework Directive can act as a driving force for other applicable legislation where such risks are not considered. We end by providing a set of recommendations for the European Commission and the Members States' future work on addressing aquatic pollution and antimicrobial resistance.
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Affiliation(s)
- Marlene Ågerstrand
- Department of Environmental Science, Stockholm University, Svante Arrhenius väg 8, 106 91, Stockholm, Sweden
| | - Henrik Josefsson
- Department of Business Studies, Commercial Law Unit, Uppsala University, Kyrkogårdsgatan 10, 751 20 Uppsala, Sweden
| | - Ann-Sofie Wernersson
- Department for Management of Contaminated Sites, Swedish Geotechnical Institute, Hugo Grauers gata 5 B, 41296 Göteborg, Sweden
| | - D. G. Joakim Larsson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Guldhedsgatan 10A, 413 46 Gothenburg, Sweden
- Centre for Antibiotic Resistance Research, University of Gothenburg, Gothenburg, Sweden
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Huijbers PMC, Bobis Camacho J, Hutinel M, Larsson DGJ, Flach CF. Sampling Considerations for Wastewater Surveillance of Antibiotic Resistance in Fecal Bacteria. Int J Environ Res Public Health 2023; 20:4555. [PMID: 36901565 PMCID: PMC10002399 DOI: 10.3390/ijerph20054555] [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] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
Wastewaters can be analyzed to generate population-level data for public health surveillance, such as antibiotic resistance monitoring. To provide representative data for the contributing population, bacterial isolates collected from wastewater should originate from different individuals and not be distorted by a selection pressure in the wastewater. Here we use Escherichia coli diversity as a proxy for representativeness when comparing grab and composite sampling at a major municipal wastewater treatment plant influent and an untreated hospital effluent in Gothenburg, Sweden. All municipal samples showed high E. coli diversity irrespective of the sampling method. In contrast, a marked increase in diversity was seen for composite compared to grab samples from the hospital effluent. Virtual resampling also showed the value of collecting fewer isolates on multiple occasions rather than many isolates from a single sample. Time-kill tests where individual E. coli strains were exposed to sterile-filtered hospital wastewater showed rapid killing of antibiotic-susceptible strains and significant selection of multi-resistant strains when incubated at 20 °C, an effect which could be avoided at 4 °C. In conclusion, depending on the wastewater collection site, both sampling method and collection/storage temperature could significantly impact the representativeness of the wastewater sample.
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Affiliation(s)
- Patricia M. C. Huijbers
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, 40530 Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Guldhedsgatan 10A, 40530 Gothenburg, Sweden
| | - Julián Bobis Camacho
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, 40530 Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Guldhedsgatan 10A, 40530 Gothenburg, Sweden
| | - Marion Hutinel
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, 40530 Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Guldhedsgatan 10A, 40530 Gothenburg, Sweden
| | - D. G. Joakim Larsson
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, 40530 Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Guldhedsgatan 10A, 40530 Gothenburg, Sweden
| | - Carl-Fredrik Flach
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, 40530 Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Guldhedsgatan 10A, 40530 Gothenburg, Sweden
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