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Choat J, Young J, Petersen JM, Dietrich EA. Antimicrobial Susceptibility of Francisella tularensis Isolates in the United States, 2009-2018. Clin Infect Dis 2024; 78:S4-S6. [PMID: 38294116 DOI: 10.1093/cid/ciad680] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
Francisella tularensis is the causative agent of tularemia. We tested the susceptibility of 278 F. tularensis isolates from the United States received during 2009-2018 to 8 antimicrobial drugs (ciprofloxacin, levofloxacin, doxycycline, tetracycline, gentamicin, streptomycin, chloramphenicol, and erythromycin). All isolates were susceptible to all tested drugs.
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Affiliation(s)
- Jamie Choat
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - John Young
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Jeannine M Petersen
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Elizabeth A Dietrich
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Maurin M, Pondérand L, Hennebique A, Pelloux I, Boisset S, Caspar Y. Tularemia treatment: experimental and clinical data. Front Microbiol 2024; 14:1348323. [PMID: 38298538 PMCID: PMC10827922 DOI: 10.3389/fmicb.2023.1348323] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/31/2023] [Indexed: 02/02/2024] Open
Abstract
Tularemia is a zoonosis caused by the Gram negative, facultative intracellular bacterium Francisella tularensis. This disease has multiple clinical presentations according to the route of infection, the virulence of the infecting bacterial strain, and the underlying medical condition of infected persons. Systemic infections (e.g., pneumonic and typhoidal form) and complications are rare but may be life threatening. Most people suffer from local infection (e.g., skin ulcer, conjunctivitis, or pharyngitis) with regional lymphadenopathy, which evolve to suppuration in about 30% of patients and a chronic course of infection. Current treatment recommendations have been established to manage acute infections in the context of a biological threat and do not consider the great variability of clinical situations. This review summarizes literature data on antibiotic efficacy against F. tularensis in vitro, in animal models, and in humans. Empirical treatment with beta-lactams, most macrolides, or anti-tuberculosis agents is usually ineffective. The aminoglycosides gentamicin and streptomycin remain the gold standard for severe infections, and the fluoroquinolones and doxycycline for infections of mild severity, although current data indicate the former are usually more effective. However, the antibiotic treatments reported in the literature are highly variable in their composition and duration depending on the clinical manifestations, the age and health status of the patient, the presence of complications, and the evolution of the disease. Many patients received several antibiotics in combination or successively. Whatever the antibiotic treatment administered, variable but high rates of treatment failures and relapses are still observed, especially in patients treated more then 2-3 weeks after disease onset. In these patients, surgical treatment is often necessary for cure, including drainage or removal of suppurative lymph nodes or other infectious foci. It is currently difficult to establish therapeutic recommendations, particularly due to lack of comparative randomized studies. However, we have attempted to summarize current knowledge through proposals for improving tularemia treatment which will have to be discussed by a group of experts. A major factor in improving the prognosis of patients with tularemia is the early administration of appropriate treatment, which requires better medical knowledge and diagnostic strategy of this disease.
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Affiliation(s)
- Max Maurin
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Translational Innovation in Medicine and Complexity (TIMC), Centre National de la Recherche Scientifique (CNRS), Grenoble, France
| | - Léa Pondérand
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
| | - Aurélie Hennebique
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Translational Innovation in Medicine and Complexity (TIMC), Centre National de la Recherche Scientifique (CNRS), Grenoble, France
| | - Isabelle Pelloux
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
| | - Sandrine Boisset
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
| | - Yvan Caspar
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
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3
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Köppen K, Rydzewski K, Doellinger J, Myrtennäs K, Forsman M, Appelt S, Scholz H, Heuner K. Phenotypic and genotypic discrimination of Francisella tularensis ssp. holarctica clades. Int J Med Microbiol 2023; 313:151583. [PMID: 37331050 DOI: 10.1016/j.ijmm.2023.151583] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023] Open
Abstract
Francisella tularensis is the causative agent of tularemia, a zoonotic disease with a wide host range. F. tularensis ssp. holarctica (Fth) is of clinical relevance for European countries, including Germany. Whole genome sequencing methods, including canonical Single Nucleotide Polymorphism (canSNP) typing and whole genome SNP typing, have revealed that European Fth strains belong to a few monophyletic populations. The majority of German Fth isolates belong to two basal phylogenetic clades B.6 (biovar I) and B.12 (biovar II). Strains of B.6 and B.12 seem to differ in their pathogenicity, and it has been shown that strains of biovar II are resistant against erythromycin. In this study, we present data corroborating our previous data demonstrating that basal clade B.12 can be divided into clades B.71 and B.72. By applying phylogenetic whole genome analysis as well as proteome analysis, we could verify that strains of these two clades are distinct from one another. This was confirmed by measuring the intensity of backscatter light on bacteria grown in liquid media. Strains belonging to clades B.6, B.71 or B.72 showed clade-specific backscatter growth curves. Furthermore, we present the whole genome sequence of strain A-1341, as a reference genome of clade B.71, and whole proteomes comparison of Fth strains belonging to clades B.6, B.71 and B.72. Further research is necessary to investigate phenotypes and putative differences in pathogenicity of the investigated different clades of Fth to better understand the relationship between observed phenotypes, pathogenicity and distribution of Fth strains.
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Affiliation(s)
- Kristin Köppen
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Kerstin Rydzewski
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Joerg Doellinger
- Centre for Biological Threats and Special Pathogens, Proteomics and Spectroscopy (ZBS 6), Robert Koch Institute, Berlin, Germany
| | - Kerstin Myrtennäs
- Division of CBRN Defence and Security, Swedish Defence Research Agency (FOI), Umeå, Sweden
| | - Mats Forsman
- Division of CBRN Defence and Security, Swedish Defence Research Agency (FOI), Umeå, Sweden
| | - Sandra Appelt
- Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Holger Scholz
- Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Klaus Heuner
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany; Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany.
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Borgschulte HS, Jacob D, Zeeh J, Scholz HC, Heuner K. Ulceroglandular form of tularemia after squirrel bite: a case report. J Med Case Rep 2022; 16:309. [PMID: 35974355 PMCID: PMC9381146 DOI: 10.1186/s13256-022-03510-8] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background The diagnosis of tularemia is not often considered in Germany as the disease is still rare in this country. Nonetheless, Francisella tularensis, the causative agent of tularemia, can infect numerous animal species and should, therefore, not be neglected as a dangerous pathogen. Tularemia can lead to massively swollen lymph nodes and might even be fatal without antibiotic treatment. To our knowledge, the case described here is the first report of the disease caused by a squirrel bite in Germany. Case presentation A 59-year-old German woman with a past medical history of hypothyroidism and cutaneous lupus erythematosus presented at the emergency room at St. Katharinen Hospital with ongoing symptoms and a swollen right elbow persisting despite antibiotic therapy with cefuroxime for 7 days after she had been bitten (right hand) by a wild squirrel (Eurasian red squirrel). After another 7 days of therapy with piperacillin/tazobactam, laboratory analysis using real-time polymerase chain reaction (PCR) confirmed the suspected diagnosis of tularemia on day 14. After starting the recommended antibiotic treatment with ciprofloxacin, the patient recovered rapidly. Conclusion This is the first report of a case of tularemia caused by a squirrel bite in Germany. A naturally infected squirrel has recently been reported in Switzerland for the first time. The number of human cases of tularemia has been increasing over the last years and, therefore, tularemia should be taken into consideration as a diagnosis, especially in a patient bitten by an animal who also presents with headache, increasing pain, lymphadenitis, and fever, as well as impaired wound healing. The pathogen can easily be identified by a specific real-time PCR assay of wound swabs and/or by antibody detection, for example by enzyme-linked immunosorbent assay (ELISA), if the incident dates back longer than 2 weeks.
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Affiliation(s)
- Hannah Sophia Borgschulte
- Department of Internal Medicine 2, St. Katharinen-Hospital, Kapellenstr. 1-5, 50226, Frechen, Germany
| | - Daniela Jacob
- Division of Highly Pathogenic Microorganisms (ZBS 2), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany
| | - Jörg Zeeh
- Department of Internal Medicine 2, St. Katharinen-Hospital, Kapellenstr. 1-5, 50226, Frechen, Germany
| | - Holger C Scholz
- Division of Highly Pathogenic Microorganisms (ZBS 2), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany
| | - Klaus Heuner
- Division of Highly Pathogenic Microorganisms (ZBS 2), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Seestr. 10, 13353, Berlin, Germany.
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Martínez-Martínez S, Rodríguez-Ferri EF, Rodríguez-Lázaro D, Hernández M, Gómez-Campillo JI, Martínez-Nistal MDC, Fernández-Natal MI, García-Iglesias MJ, Mínguez-González O, Gutiérrez-Martín CB. In Vitro Antimicrobial Susceptibilities of Francisella tularensis subsp. holarctica Isolates from Tularemia Outbreaks That Occurred from the End of the 20th Century to the 2020s in Spain. Antibiotics (Basel) 2021; 10:938. [PMID: 34438988 DOI: 10.3390/antibiotics10080938] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/13/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
A collection of 177 Francisella tularensis subsp. holarctica clinical isolates (29 from humans and 148 from animals, mainly hares and voles) was gathered from diverse tularemia outbreaks in the Castilla y León region (northwestern Spain) that occurred from the end of the 20th century to the 2020s. Along with four F. tularensis subsp. holarctica reference strains, all of these clinical isolates were tested using a broth microdilution method to determine their susceptibility to 22 antimicrobial agents, including β-lactams, aminoglycosides and one member each of the tetracycline, glycylcycline, quinolone and sulphonamide classes. Many multi-resistance profiles were found among the tested isolates, but especially among those of human origin (all but two isolates showed resistance to at least 13 of 18 antimicrobial agents). Even so, all human isolates were susceptible to gentamicin and tobramycin, while more than 96% of animal isolates were susceptible to these two aminoglycosides. Ciprofloxacin showed activity against more than 92% of animal and human isolates. However, almost 21% of human isolates were resistant to tetracycline, and more than 65% were resistant to tigecycline. Finally, a quite similar activity to other F. tularensis subsp. holarctica isolates collected 20 years earlier in Spain was observed.
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Biot FV, Bachert BA, Mlynek KD, Toothman RG, Koroleva GI, Lovett SP, Klimko CP, Palacios GF, Cote CK, Ladner JT, Bozue JA. Evolution of Antibiotic Resistance in Surrogates of Francisella tularensis (LVS and Francisella novicida): Effects on Biofilm Formation and Fitness. Front Microbiol 2020; 11:593542. [PMID: 33193267 PMCID: PMC7661474 DOI: 10.3389/fmicb.2020.593542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/10/2020] [Accepted: 10/08/2020] [Indexed: 11/15/2022] Open
Abstract
Francisella tularensis, the causative agent of tularemia, is capable of causing disease in a multitude of mammals and remains a formidable human pathogen due to a high morbidity, low infectious dose, lack of a FDA approved vaccine, and ease of aerosolization. For these reasons, there is concern over the use of F. tularensis as a biological weapon, and, therefore, it has been classified as a Tier 1 select agent. Fluoroquinolones and aminoglycosides often serve as the first line of defense for treatment of tularemia. However, high levels of resistance to these antibiotics has been observed in gram-negative bacteria in recent years, and naturally derived resistant Francisella strains have been described in the literature. The acquisition of antibiotic resistance, either natural or engineered, presents a challenge for the development of medical countermeasures. In this study, we generated a surrogate panel of antibiotic resistant F. novicida and Live Vaccine Strain (LVS) by selection in the presence of antibiotics and characterized their growth, biofilm capacity, and fitness. These experiments were carried out in an effort to (1) assess the fitness of resistant strains; and (2) identify new targets to investigate for the development of vaccines or therapeutics. All strains exhibited a high level of resistance to either ciprofloxacin or streptomycin, a fluoroquinolone and aminoglycoside, respectively. Whole genome sequencing of this panel revealed both on-pathway and off-pathway mutations, with more mutations arising in LVS. For F. novicida, we observed decreased biofilm formation for all ciprofloxacin resistant strains compared to wild-type, while streptomycin resistant isolates were unaffected in biofilm capacity. The fitness of representative antibiotic resistant strains was assessed in vitro in murine macrophage-like cell lines, and also in vivo in a murine model of pneumonic infection. These experiments revealed that mutations obtained by these methods led to nearly all ciprofloxacin resistant Francisella strains tested being completely attenuated while mild attenuation was observed in streptomycin resistant strains. This study is one of the few to examine the link between acquired antibiotic resistance and fitness in Francisella spp., as well as enable the discovery of new targets for medical countermeasure development.
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Affiliation(s)
- Fabrice V Biot
- Institut de Recherche Biomédicale des Armées, Département de Biologie des Agents Transmissibles, Unité de Bactériologie/UMR_MD1, Brétigny-sur-Orge, France
| | - Beth A Bachert
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Kevin D Mlynek
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Ronald G Toothman
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Galina I Koroleva
- Center for Genome Sciences, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Sean P Lovett
- Center for Genome Sciences, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Christopher P Klimko
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Gustavo F Palacios
- Center for Genome Sciences, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Christopher K Cote
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Jason T Ladner
- Center for Genome Sciences, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
| | - Joel A Bozue
- Bacteriology Division, U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, United States
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Seiwald S, Simeon A, Hofer E, Weiss G, Bellmann-Weiler R. Tularemia Goes West: Epidemiology of an Emerging Infection in Austria. Microorganisms 2020; 8:E1597. [PMID: 33081341 PMCID: PMC7602993 DOI: 10.3390/microorganisms8101597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 08/31/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/16/2022] Open
Abstract
The zoonotic disease tularemia is caused by the Gram-negative bacterium Francisella tularensis, with the two major subspecies tularensis and holarctica being responsible for infections in humans and animals. The F. tularensis subspecies holarctica is less virulent and prevalent in Europe and Asia. Over the last few centuries, few epidemic outbreaks and low numbers of infections have been registered in the eastern part of Austria, specifically in the provinces of Lower Austria, Burgenland, and Styria. The reported infections were mostly associated with hunting hares and the skinning of carcasses. Within the last decade, ticks have been identified as important vectors in Tyrol and served as first evidence for the spread of F. tularensis to Western Austria. In 2018, the pathogen was detected in hares in the provinces of Tyrol, Vorarlberg, and Salzburg. We presume that F. tularensis is now established in most regions of Austria, and that the investigation of potential host and vector animals should be spotlighted by public institutions. Tularemia in humans presents with various clinical manifestations. As glandular, ulceroglandular, and typhoidal forms occur in Austria, this infectious disease should be considered as a differential diagnosis of unknown fever.
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Affiliation(s)
- Stefanie Seiwald
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.); (A.S.); (G.W.)
| | - Anja Simeon
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.); (A.S.); (G.W.)
| | - Erwin Hofer
- Institute for Veterinary Disease Control, Austrian Agency for Health and Food Safety (AGES), 2340 Mödling, Austria;
| | - Günter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.); (A.S.); (G.W.)
| | - Rosa Bellmann-Weiler
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.); (A.S.); (G.W.)
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8
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Appelt S, Faber M, Köppen K, Jacob D, Grunow R, Heuner K. Francisella tularensis Subspecies holarctica and Tularemia in Germany. Microorganisms 2020; 8:microorganisms8091448. [PMID: 32971773 PMCID: PMC7564102 DOI: 10.3390/microorganisms8091448] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 08/27/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/26/2022] Open
Abstract
Tularemia is a zoonotic disease caused by Francisella tularensis a small, pleomorphic, facultative intracellular bacterium. In Europe, infections in animals and humans are caused mainly by Francisella tularensis subspecies holarctica. Humans can be exposed to the pathogen directly and indirectly through contact with sick animals, carcasses, mosquitoes and ticks, environmental sources such as contaminated water or soil, and food. So far, F. tularensis subsp. holarctica is the only Francisella species known to cause tularemia in Germany. On the basis of surveillance data, outbreak investigations, and literature, we review herein the epidemiological situation-noteworthy clinical cases next to genetic diversity of F. tularensis subsp. holarctica strains isolated from patients. In the last 15 years, the yearly number of notified cases of tularemia has increased steadily in Germany, suggesting that the disease is re-emerging. By sequencing F. tularensis subsp. holarctica genomes, knowledge has been added to recent findings, completing the picture of genotypic diversity and geographical segregation of Francisella clades in Germany. Here, we also shortly summarize the current knowledge about a new Francisella species (Francisella sp. strain W12-1067) that has been recently identified in Germany. This species is the second Francisella species discovered in Germany.
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Affiliation(s)
- Sandra Appelt
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Mirko Faber
- Gastrointestinal Infections, Zoonoses and Tropical Infections (Division 35), Department for Infectious Disease Epidemiology, Robert Koch Institute, 13353 Berlin, Germany;
| | - Kristin Köppen
- Cellular Interactions of Bacterial Pathogens, ZBS 2, Robert Koch Institute, 13353 Berlin, Germany;
| | - Daniela Jacob
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Roland Grunow
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Klaus Heuner
- Cellular Interactions of Bacterial Pathogens, ZBS 2, Robert Koch Institute, 13353 Berlin, Germany;
- Correspondence: ; Tel.: +49-301-8754-2226
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9
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Appelt S, Köppen K, Radonić A, Drechsel O, Jacob D, Grunow R, Heuner K. Genetic Diversity and Spatial Segregation of Francisella tularensis Subspecies holarctica in Germany. Front Cell Infect Microbiol 2019; 9:376. [PMID: 31781515 PMCID: PMC6851236 DOI: 10.3389/fcimb.2019.00376] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 07/22/2019] [Accepted: 10/17/2019] [Indexed: 01/28/2023] Open
Abstract
Francisella tularensis is an intracellular pleomorphic bacterium and the causative agent of tularemia, a zoonotic disease with a wide host range. Among the F. tularensis subspecies, especially F. tularensis subsp. holarctica is of clinical relevance for European countries. The study presented herein focuses namely on genetic diversity and spatial segregation of F. tularensis subsp. holarctica in Germany, as still limited information is available. The investigation is based on the analysis of 34 F. tularensis subsp. holarctica isolates and one draft genome from an outbreak strain. The isolates were cultured from sample material being that of primarily human patients (n = 25) and free-living animals (n = 9). For six of 25 human isolates, epidemiological links between disease onset and tick bites could be established, confirming the importance of arthropod linked transmission of tularemia in Germany. The strains were assigned to three of four major F. tularensis subsp. holarctica clades: B.4, B.6, and B.12. Thereby, B.6 and B.12 clade members were predominantly found; only one human isolate was assigned to clade B.4. Also, it turned out that eight isolates which caused pneumonia in patients clustered into the B.6 clade. Altogether, eight different final subclades were assigned to clade B.6 (biovar I, erythromycin sensitive) and six to B.12 (biovar II, erythromycin resistant) in addition to one new final B.12 subclade. Moreover, for 13 human and 3 animal isolates, final subclade subdivisions were not assigned (B.12 subdivisions B.33 and B.34, and B.6 subdivision B.45) because official nomenclatures are not available yet. This gives credit to the genetic variability of F. tularensis subsp. holarctica strains in Germany. The results clearly point out that the given genetic diversity in Germany seems to be comparably high to that found in other European countries including Scandinavian regions. A spatial segregation of B.6 and B.12 strains was found and statistically confirmed, and B.12 clade members were predominantly found in eastern parts and B.6 members more in western to southern parts of Germany. The portion of B.12 clade members in northeastern parts of Germany was 78.5% and in southwestern parts 1.9%.
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Affiliation(s)
- Sandra Appelt
- Centre for Biological Threats and Special Pathogens (ZBS2), Robert Koch Institute, Berlin, Germany
| | - Kristin Köppen
- Working Group Cellular Interactions of Bacterial Pathogens, ZBS2, Robert Koch Institute, Berlin, Germany
| | - Aleksandar Radonić
- Methodology and Research Infrastructure Genome Sequencing (MF2), Robert Koch Institute, Berlin, Germany
| | - Oliver Drechsel
- Bioinformatics (MF1), Robert Koch Institute, Berlin, Germany
| | - Daniela Jacob
- Centre for Biological Threats and Special Pathogens (ZBS2), Robert Koch Institute, Berlin, Germany
| | - Roland Grunow
- Centre for Biological Threats and Special Pathogens (ZBS2), Robert Koch Institute, Berlin, Germany
| | - Klaus Heuner
- Working Group Cellular Interactions of Bacterial Pathogens, ZBS2, Robert Koch Institute, Berlin, Germany
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Rothweiler R, Fuessinger MA, Schmelzeisen R, Metzger MC. Lymph node abscess caused by Francisella tularensis - a rare differential diagnosis for cervical lymph node swelling: a case report. J Med Case Rep 2019; 13:247. [PMID: 31395094 PMCID: PMC6688270 DOI: 10.1186/s13256-019-2165-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical lymph node swelling is quite a common symptom mainly caused by infections in the face or as metastasis of a malignant tumor. In infection cases in particular, rare diseases should never be overlooked. With an incidence of 120 cases in the United States of America (USA) and approximately 25 cases in Germany per year, infection with the pathogen Francisella tularensis is one of these rare diseases that can cause massive lymph node swellings and might even be fatal. CASE PRESENTATION The example of a healthy 67-year-old German woman who was treated at our university hospital presents a typical progression of a localized form of tularemia. The pathogen could be identified in a universal 16S ribosomal deoxyribonucleic acid (DNA) polymerase chain reaction. Pathogen-specific treatment with lymph node abscess incision, daily rinsing of the abscess cavity, and orally administered antibiotic therapy with doxycycline could cure our patient completely without any remaining complications. CONCLUSION In patients with cervical lymph node swelling caused by infection it is indispensable to perform specific identification of the pathogen for further local and specific antibiotic treatment. Possible infections with atypical bacteria like Francisella tularensis should never be ignored. Universal polymerase chain reactions are a suitable method for early detection of such rare pathogens.
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Affiliation(s)
- R. Rothweiler
- Department of Oral and Maxillofacial Surgery Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - M. A. Fuessinger
- Department of Oral and Maxillofacial Surgery Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - R. Schmelzeisen
- Department of Oral and Maxillofacial Surgery Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - M. C. Metzger
- Department of Oral and Maxillofacial Surgery Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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Chrdle A, Trnka T, Musil D, Fucentese SF, Bode P, Keller PM, Achermann Y. Francisella tularensis Periprosthetic Joint Infections Diagnosed with Growth in Cultures. J Clin Microbiol 2019; 57:e00339-19. [PMID: 31189580 DOI: 10.1128/JCM.00339-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/27/2019] [Indexed: 01/02/2023] Open
Abstract
Tularemia caused by Francisella tularensis is a zoonotic infection of the Northern Hemisphere that mainly affects the skin, lymph nodes, bloodstream, and lungs. Other manifestations of tularemia are very rare, especially those with musculoskeletal involvement. Presenting in 2016, we diagnosed two cases of periprosthetic knee joint infections (PJI) caused by Francisella tularensis in Europe (one in Switzerland and one in the Czech Republic). We found only two other PJI cases in the literature, another knee PJI diagnosed 1999 in Ontario, Canada, and one hip PJI in Illinois, USA, in 2017. Diagnosis was made in all cases by positive microbiological cultures after 3, 4, 7, and 12 days. All were successfully treated, two cases by exchange of the prosthesis, one with debridement and retention, and one with repeated aspiration of the synovial fluid only. Antibiotic treatment was given between 3 weeks and 12 months with either ciprofloxacin-rifampin or with doxycycline alone or doxycycline in combination with gentamicin. Zoonotic infections should be considered in periprosthetic infections in particular in culture-negative PJIs with a positive histology or highly elevated leukocyte levels in synovial aspiration. Here, we recommend prolonging cultivation time up to 14 days, performing specific PCR tests, and/or conducting epidemiologically appropriate serological tests for zoonotic infections, including that for F. tularensis.
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Caspar Y, Hennebique A, Maurin M. Antibiotic susceptibility of Francisella tularensis subsp. holarctica strains isolated from tularaemia patients in France between 2006 and 2016. J Antimicrob Chemother 2019; 73:687-691. [PMID: 29253157 DOI: 10.1093/jac/dkx460] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/06/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives To determine the in vitro susceptibility to 18 antibiotics of human strains of Francisella tularensis isolated in France between 2006 and 2016, to check the absence of acquired resistance and to evaluate potential therapeutic alternatives. Methods Fifty-nine clinically unrelated F. tularensis subsp. holarctica strains identified at the French National Reference Centre for Francisella as belonging to the phylogenetic subclade B.FTNF002-00 were used. MICs were determined in CAMHB medium supplemented with 2% PolyViteX®, using the CLSI broth microdilution method. Results All strains were susceptible to fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin and moxifloxacin; MIC range: 0.016-0.25 mg/L), aminoglycosides (gentamicin and tobramycin; MIC range: ≤0.03-0.25 mg/L), doxycycline (MIC range: 0.125-0.25 mg/L) and chloramphenicol (MIC range: 0.5-2 mg/L). The erythromycin MIC range (0.5-2 mg/L) confirmed that all isolates belonged to biovar I of F. tularensis subsp. holarctica. Azithromycin and telithromycin displayed lower MIC ranges (0.25-1 and 0.03-0.5 mg/L, respectively). The tigecycline MIC range (0.25-1 mg/L) was slightly higher than that of doxycycline. All strains were resistant to ampicillin, meropenem, daptomycin, clindamycin and linezolid. Conclusions F. tularensis strains isolated in France remain susceptible to antibiotic classes recommended for tularaemia treatment. Because fluoroquinolones display the lowest MIC90, have bactericidal activity and have lower therapeutic failure rates compared with doxycycline, they may be advocated as first-line treatment of mild cases of tularaemia, predominant in Europe. MIC data also indicate that azithromycin or telithromycin may be possible therapeutic options against biovar I strains from Western Europe in case of contraindication to first-line antibiotics.
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Affiliation(s)
- Yvan Caspar
- Centre National de Référence Francisella tularensis, Laboratoire de Bactériologie-Hygiène Hospitalière, Département des agents infectieux, Institut de Biologie et de Pathologie, Centre Hospitalier Universitaire Grenoble Alpes, CS 10217, F-38043 Grenoble cedex 9, France.,Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France
| | - A Hennebique
- Centre National de Référence Francisella tularensis, Laboratoire de Bactériologie-Hygiène Hospitalière, Département des agents infectieux, Institut de Biologie et de Pathologie, Centre Hospitalier Universitaire Grenoble Alpes, CS 10217, F-38043 Grenoble cedex 9, France.,Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France
| | - Max Maurin
- Centre National de Référence Francisella tularensis, Laboratoire de Bactériologie-Hygiène Hospitalière, Département des agents infectieux, Institut de Biologie et de Pathologie, Centre Hospitalier Universitaire Grenoble Alpes, CS 10217, F-38043 Grenoble cedex 9, France.,Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France
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Frischknecht M, Meier A, Mani B, Joerg L, Kim OC, Boggian K, Strahm C. Tularemia: an experience of 13 cases including a rare myocarditis in a referral center in Eastern Switzerland (Central Europe) and a review of the literature. Infection 2019; 47:683-95. [PMID: 30656604 DOI: 10.1007/s15010-019-01269-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/06/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Tularemia, a zoonotic disease caused by Francisella tularensis, can cause a broad spectrum of disease in humans including six major clinical presentations: the ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal and pneumonic form. The epidemiology and ecology and thus transmission of tularemia are complex, depending on conditions unique to specific locations. CASE SERIES AND METHODS Thirteen cases with different forms of the disease and one very rare case of a myocarditis are reported, discussed, and reviewed within the scope of current literature. CONCLUSION Tularemia is a rare, but emerging disease in Central Europe with glandular and ulceroglandular disease as its predominant forms. Transmission is mainly caused by contact with lagomorphs, rodents and tick bites. However, domestic cats may play an important role in transmission too. Myocarditis is probably a worldwide, but very rare manifestation of tularemia.
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14
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Busch A, Thomas P, Zuchantke E, Brendebach H, Neubert K, Gruetzke J, Al Dahouk S, Peters M, Hotzel H, Neubauer H, Tomaso H. Revisiting Francisella tularensis subsp. holarctica, Causative Agent of Tularemia in Germany With Bioinformatics: New Insights in Genome Structure, DNA Methylation and Comparative Phylogenetic Analysis. Front Microbiol 2018; 9:344. [PMID: 29593661 PMCID: PMC5859110 DOI: 10.3389/fmicb.2018.00344] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 12/05/2017] [Accepted: 02/12/2018] [Indexed: 12/30/2022] Open
Abstract
Francisella (F.) tularensis is a highly virulent, Gram-negative bacterial pathogen and the causative agent of the zoonotic disease tularemia. Here, we generated, analyzed and characterized a high quality circular genome sequence of the F. tularensis subsp. holarctica strain 12T0050 that caused fatal tularemia in a hare. Besides the genomic structure, we focused on the analysis of oriC, unique to the Francisella genus and regulating replication in and outside hosts and the first report on genomic DNA methylation of a Francisella strain. The high quality genome was used to establish and evaluate a diagnostic whole genome sequencing pipeline. A genotyping strategy for F. tularensis was developed using various bioinformatics tools for genotyping. Additionally, whole genome sequences of F. tularensis subsp. holarctica isolates isolated in the years 2008–2015 in Germany were generated. A phylogenetic analysis allowed to determine the genetic relatedness of these isolates and confirmed the highly conserved nature of F. tularensis subsp. holarctica.
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Affiliation(s)
- Anne Busch
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Prasad Thomas
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Eric Zuchantke
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Holger Brendebach
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Kerstin Neubert
- Algorithmic Bioinformatics, Department of Mathematics and Computer Science, Institute of Computer Science, Freie Universität Berlin, Berlin, Germany
| | - Josephine Gruetzke
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Sascha Al Dahouk
- Department of Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Martin Peters
- Standort Arnsberg, Chemisches und Veterinäruntersuchungsamt Westfalen, Arnsberg, Germany
| | - Helmut Hotzel
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Heinrich Neubauer
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
| | - Herbert Tomaso
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Jena, Germany
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15
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Abstract
Tularemia, also known as “rabbit fever,” is a zoonosis caused by the facultative intracellular, gram-negative bacterium Francisella tularensis. Infection occurs through contact with infected animals (often hares), arthropod vectors (such as ticks or deer flies), inhalation of contaminated dust or through contaminated food and water. In this review, we would like to provide an overview of the current epidemiological situation in Germany using published studies and case reports, an analysis of recent surveillance data and our own experience from the laboratory diagnostics, and investigation of cases. While in Germany tularemia is a rarely reported disease, there is evidence of recent re-emergence. We also describe some peculiarities that were observed in Germany, such as a broad genetic diversity, and a recently discovered new genus of Francisella and protracted or severe clinical courses of infections with the subspecies holarctica. Because tularemia is a zoonosis, we also touch upon the situation in the animal reservoir and one-health aspects of this disease. Apparently, many pieces of the puzzle need to be found and put into place before the complex interaction between wildlife, the environment and humans are fully understood. Funding for investigations into rare diseases is scarce. Therefore, combining efforts in several countries in the framework of international projects may be necessary to advance further our understanding of this serious but also scientifically interesting disease.
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Affiliation(s)
- Mirko Faber
- Gastrointestinal Infections, Zoonoses and Tropical Infections (Division 35), Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Klaus Heuner
- Working Group, Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Division 2 (ZBS 2), Robert Koch Institute, Berlin, Germany.,Highly Pathogenic Microorganisms, Centre for Biological Threats and Special Pathogens, Division 2 (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Daniela Jacob
- Highly Pathogenic Microorganisms, Centre for Biological Threats and Special Pathogens, Division 2 (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Roland Grunow
- Highly Pathogenic Microorganisms, Centre for Biological Threats and Special Pathogens, Division 2 (ZBS 2), Robert Koch Institute, Berlin, Germany
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Tomaso H, Otto P, Peters M, Süss J, Karger A, Schamoni H, Zuchantke E, Hotzel H. Francisella tularensis and other bacteria in hares and ticks in North Rhine-Westphalia (Germany). Ticks Tick Borne Dis 2017; 9:325-329. [PMID: 29239792 DOI: 10.1016/j.ttbdis.2017.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 11/25/2022]
Abstract
Tularemia is a zoonotic disease caused by the bacterium Francisella tularensis. The disease can be transmitted to humans through contact with infected animals such as the European brown hare (Lepus europaeus) and ticks as vectors. The aim of this study was to isolate F. tularensis from ticks and hares in North Rhine-Westphalia using cysteine heart agar to determine their genetic relatedness and to identify other bacteria that grow on this medium. 848 European brown hares and 1556 questing ticks (all Ixodes ricinus) from forests were tested using cultivation and MALDI-TOF mass spectrometry or partial 16S rRNA gene sequencing. The majority of F. tularensis isolates from hares (n=24; 96%) and genomic F. tularensis DNA recovered from ticks belonged to the basal genetic clade IV and subclade B.18. These isolates were sensitive to erythromycin and were assigned to biovar I. Only a single strain isolated from a hare was assigned to basal clade I (B.12/B.35). All isolates were sensitive to tetracycline, doxycycline, streptomycin, gentamicin, chloramphenicol, and ciprofloxacin. Only 4 tick pools were positive for F. tularensis and cultivation was not successful in any of the pools. Most of the other isolated bacteria belonged to the order Bacillales with 36 Staphylococcus isolates, 9 Bacillus isolates and 8 Paenibacillus isolates. Prominent members of Enterobacterales were represented by different genera like Pantoea, Erwinia, Raoultella etc. Several of the bacterial species were soil or plant-associated, but some of the bacterial species were found in I. ricinus for the first time. Our results showed that F. tularensis was detected only in few ticks of an endemic area, but ticks were also infected by several other bacteria with zoonotic potential. Therefore, a wider spectrum of pathogens should be considered if a patient was bitten by a tick.
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Affiliation(s)
- Herbert Tomaso
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Strasse 96a, 07743 Jena, Germany.
| | - Peter Otto
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Strasse 96a, 07743 Jena, Germany.
| | - Martin Peters
- Chemisches und Veterinäruntersuchungsamt Westfalen, Standort Arnsberg, Zur Taubeneiche 10-12, 59821 Arnsberg, Germany.
| | - Jochen Süss
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Strasse 96a, 07743 Jena, Germany.
| | - Axel Karger
- Friedrich-Loeffler-Institut, Institute of Molecular Virology and Cell Biology, Südufer 10, 17493 Greifswald-Insel Riems, Germany.
| | | | - Eric Zuchantke
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Strasse 96a, 07743 Jena, Germany.
| | - Helmut Hotzel
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Strasse 96a, 07743 Jena, Germany.
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