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Senhaji-Kacha A, Akir A, Broncano-Lavado A, Esteban J. Biofilm prevention concentration of clarithromycin against clinically relevant species of nontuberculous mycobacteria. Rev Esp Quimioter 2024; 37:266-269. [PMID: 38602224 DOI: 10.37201/req/014.2024] [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] [Indexed: 04/12/2024]
Abstract
OBJECTIVE Mycobacterium avium complex (MAC) and Mycobacterium abscessus are a group of nontuberculous mycobacteria (NTM) that have been described as human pathogens. Their ability to develop biofilms in tissues and medical devices is one of the most important pathogenicity factors, with important implications in diagnosis and treatment. Macrolides are usually considered one of the bases of this treatment. METHODS Here we have studied the biofilm prevention concentration (BPC) of 16 strains (n=16) with clarithromycin to avoid the biofilm development by these NTM. RESULTS In this study, all M. abscessus strains have similar BPC, while MAC strains showed different values. For MAC the concentrations ranged between 1-16 mg/L, while for M. abscessus the concentration was 32 mg/L for all strains except one that was 64 mg/L. CONCLUSIONS These results open the possibility of using macrolides for the prevention of biofilm development in patients with a risk of developing NTM disease.
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Affiliation(s)
| | | | | | - J Esteban
- Jaime Esteban, MD, PhD.Department of ClinicalMicrobiology. IIS-Fundación Jiménez Díaz. Av. Reyes Católicos, 2. 28040-Madrid, Spain. ;
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Buenestado-Serrano S, Martínez-Lirola M, Herranz-Martín M, Esteban J, Broncano-Lavado A, Molero-Salinas A, Sanz-Pérez A, Blázquez J, Ruedas-López A, Toro C, López-Roa P, Domingo D, Zamarrón E, Ruiz Serrano MJ, Muñoz P, Pérez-Lago L, García de Viedma D. Microevolution, reinfection and highly complex genomic diversity in patients with sequential isolates of Mycobacterium abscessus. Nat Commun 2024; 15:2717. [PMID: 38548737 PMCID: PMC10979023 DOI: 10.1038/s41467-024-46552-w] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/01/2024] [Indexed: 04/01/2024] Open
Abstract
Mycobacterium abscessus is an opportunistic, extensively drug-resistant non-tuberculous mycobacterium. Few genomic studies consider its diversity in persistent infections. Our aim was to characterize microevolution/reinfection events in persistent infections. Fifty-three sequential isolates from 14 patients were sequenced to determine SNV-based distances, assign resistance mutations and characterize plasmids. Genomic analysis revealed 12 persistent cases (0-13 differential SNVs), one reinfection (15,956 SNVs) and one very complex case (23 sequential isolates over 192 months), in which a first period of persistence (58 months) involving the same genotype 1 was followed by identification of a genotype 2 (76 SNVs) in 6 additional alternating isolates; additionally, ten transient genotypes (88-243 SNVs) were found. A macrolide resistance mutation was identified from the second isolate. Despite high diversity, the genotypes shared a common phylogenetic ancestor and some coexisted in the same specimens. Genomic analysis is required to access the true intra-patient complexity behind persistent infections involving M. abscessus.
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Affiliation(s)
- Sergio Buenestado-Serrano
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Escuela de Doctorado, Universidad de Alcalá, Plaza de San Diego, s/n, 28801, Alcalá de Henares, Madrid, Spain
| | | | - Marta Herranz-Martín
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Jaime Esteban
- Servicio de Microbiología, Instituto de Investigación Sanitaria Fundación Jiménez Díaz-UAM, Hospital Universitario La Fundación Jiménez Díaz, Av. de los Reyes Católicos, 28040, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas - CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Broncano-Lavado
- Servicio de Microbiología, Instituto de Investigación Sanitaria Fundación Jiménez Díaz-UAM, Hospital Universitario La Fundación Jiménez Díaz, Av. de los Reyes Católicos, 28040, Madrid, Spain
| | - Andrea Molero-Salinas
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Amadeo Sanz-Pérez
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Jesús Blázquez
- Department of Microbial Biotechnology, National Center for Biotechnology, Consejo Superior de Investigaciones Científicas (CSIC), C/ Darwin, 3, Campus de la Universidad Autónoma-Cantoblanco, 28049, Madrid, Spain
| | - Alba Ruedas-López
- Microbiología y Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Av. de Córdoba, s/n, 28041, Madrid, Spain
| | - Carlos Toro
- Servicio de Microbiología y Parasitología, Hospital Universitario La Paz - IdiPAZ, Madrid, Spain
| | - Paula López-Roa
- Microbiología y Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Av. de Córdoba, s/n, 28041, Madrid, Spain
| | - Diego Domingo
- Servicio de Microbiología, Instituto de Investigación Sanitaria, Hospital Universitario La Princesa, Calle de Diego de León, 62, 28006, Madrid, Spain
| | - Ester Zamarrón
- Servicio de Neumología, Hospital Universitario La Paz -IdiPAZ, Madrid, Spain
| | - María Jesús Ruiz Serrano
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias - CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias - CIBERES, Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Medicina, Universidad Complutense, Av. Séneca, 2, 28040, Madrid, Spain
| | - Laura Pérez-Lago
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain.
| | - Darío García de Viedma
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias - CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
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Santamaría-Corral G, Senhaji-Kacha A, Broncano-Lavado A, Esteban J, García-Quintanilla M. Bacteriophage-Antibiotic Combination Therapy against Pseudomonas aeruginosa. Antibiotics (Basel) 2023; 12:1089. [PMID: 37508185 PMCID: PMC10376841 DOI: 10.3390/antibiotics12071089] [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: 04/04/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Phage therapy is an alternative therapy that is being used as the last resource against infections caused by multidrug-resistant bacteria after the failure of standard treatments. Pseudomonas aeruginosa can cause pneumonia, septicemia, urinary tract, and surgery site infections mainly in immunocompromised people, although it can cause infections in many different patient profiles. Cystic fibrosis patients are particularly vulnerable. In vitro and in vivo studies of phage therapy against P. aeruginosa include both bacteriophages alone and combined with antibiotics. However, the former is the most promising strategy utilized in clinical infections. This review summarizes the recent studies of phage-antibiotic combinations, highlighting the synergistic effects of in vitro and in vivo experiments and successful treatments in patients.
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Affiliation(s)
| | - Abrar Senhaji-Kacha
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Av. Reyes Católicos 2, 28040 Madrid, Spain
- CIBERINFEC-Infectious Diseases CIBER, 28029 Madrid, Spain
| | - Antonio Broncano-Lavado
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Av. Reyes Católicos 2, 28040 Madrid, Spain
- CIBERINFEC-Infectious Diseases CIBER, 28029 Madrid, Spain
| | - Meritxell García-Quintanilla
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Av. Reyes Católicos 2, 28040 Madrid, Spain
- CIBERINFEC-Infectious Diseases CIBER, 28029 Madrid, Spain
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4
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Ruedas-López A, Tato M, Broncano-Lavado A, Esteban J, Ruiz-Serrano MJ, Sánchez-Cueto M, Toro C, Domingo D, Cacho J, Barrado L, López-Roa P. Subspecies Distribution and Antimicrobial Susceptibility Testing of Mycobacterium abscessus Clinical Isolates in Madrid, Spain: a Retrospective Multicenter Study. Microbiol Spectr 2023; 11:e0504122. [PMID: 37212700 PMCID: PMC10269645 DOI: 10.1128/spectrum.05041-22] [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] [Received: 12/07/2022] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
Mycobacterium abscessus (MABS) is the most pathogenic and drug-resistant rapidly growing mycobacteria. However, studies on MABS epidemiology, especially those focusing on subspecies level, are scarce. We aimed to determine MABS subspecies distribution and its correlation with phenotypic and genotypic antibiotic profiles. A retrospective multicenter study of 96 clinical MABS isolates in Madrid between 2016 to 2021 was conducted. Identification at the subspecies level and resistance to macrolides and aminoglycosides were performed by the GenoType NTM-DR assay. The MICs of 11 antimicrobials tested against MABS isolates were determined using the broth microdilution method (RAPMYCOI Sensititer titration plates). Clinical isolates included 50 (52.1%) MABS subsp. abscessus; 33 (34.4%) MABS subsp. massiliense; and 13 (13.5%) MABS subsp. bolletii. The lowest resistance rates corresponded to amikacin (2.1%), linezolid (6.3%), cefoxitin (7.3%), and imipenem (14.6%), and the highest to doxycycline (100.0%), ciprofloxacin (89.6%), moxifloxacin (82.3%), cotrimoxazole (82.3%), tobramycin (81.3%), and clarithromycin (50.0% at day 14 of incubation). Regarding tigecycline, although there are no susceptibility breakpoints, all strains but one showed MICs ≤ 1 μg/mL. Four isolates harbored mutations at positions 2058/9 of the rrl gene, one strain harbored a mutation at position 1408 of the rrl gene, and 18/50 harbored the T28C substitution at erm(41) gene. Agreement of the GenoType results with clarithromycin and amikacin susceptibility testing was 99.0% (95/96). The rate of MABS isolates showed an upward trend during the study period, being M. abscessus subsp. abscessus the most frequently isolated subspecies. Amikacin, cefoxitin, linezolid, and imipenem showed great in vitro activity. The GenoType NTM-DR assay provides a reliable and complementary tool to broth microdilution for drug resistance detection. IMPORTANCE Infections caused by Mycobacterium abscessus (MABS) are increasingly being reported worldwide. Identifying MABS subspecies and assessing their phenotypic resistance profiles are crucial for optimal management and better patient outcomes. M. abscessus subspecies differ in erm(41) gene functionality, which is a critical determinant of macrolide resistance. Additionally, resistance profiles of MABS and the subspecies distribution can vary geographically, highlighting the importance of understanding local epidemiology and resistance patterns. This study provides valuable insights into the epidemiology and resistance patterns of MABS and its subspecies in Madrid. Elevated resistance rates were observed for several recommended antimicrobials, emphasizing the need for cautious drug use. Furthermore, we assessed the GenoType NTM-DR assay, which examines principal mutations in macrolides and aminoglycosides resistance-related genes. We observed a high level of agreement between the GenoType NTM-DR assay and the microdilution method, indicating its usefulness as an initial tool for early initiation of appropriate therapy.
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Affiliation(s)
- Alba Ruedas-López
- Clinical Microbiology and Parasitology Department, Instituto de Investigación, Hospital Universitario, Madrid, Spain.
| | - Marta Tato
- Clinical Microbiology and Parasitology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Antonio Broncano-Lavado
- Clinical Microbiology and Parasitology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Jaime Esteban
- Clinical Microbiology and Parasitology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades infecciosas CIBERINFEC, Spain
| | - María Jesús Ruiz-Serrano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
- Clinical Microbiology and Infectious Diseases, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias- CIBERES (CB06/06/0058), Madrid, Spain
| | - María Sánchez-Cueto
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
- Clinical Microbiology and Infectious Diseases, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias- CIBERES (CB06/06/0058), Madrid, Spain
| | - Carlos Toro
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Diego Domingo
- Clinical Microbiology and Parasitology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Juana Cacho
- Clinical Microbiology and Parasitology Department, Hospital Universitario de Getafe, Madrid, Spain
| | - Laura Barrado
- Clinical Microbiology and Parasitology Department, Hospital Universitario de Móstoles, Madrid, Spain
| | - Paula López-Roa
- Clinical Microbiology and Parasitology Department, Instituto de Investigación, Hospital Universitario, Madrid, Spain.
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Broncano-Lavado A, Barrado L, Lopez-Roa P, Cacho J, Domingo D, Hernandez S, Garcia-Martinez J, Millan MR, Perez-Cecilia E, Ruiz-Serrano MJ, Salso S, Simon M, Tato M, Toro C, Valverde-Canovas JF, Esteban J. Clinical Evaluation of Nontuberculous Mycobacteria (NTM) Elite Agar, a New Medium for the Isolation of NTM: a Multicenter Study. J Clin Microbiol 2023; 61:e0003623. [PMID: 36975783 PMCID: PMC10117115 DOI: 10.1128/jcm.00036-23] [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] [Received: 01/09/2023] [Accepted: 03/04/2023] [Indexed: 03/29/2023] Open
Abstract
Nontuberculous mycobacteria (NTM) are gaining interest with the increased number of infected patients. NTM Elite agar is designed specifically for the isolation of NTM without the decontamination step. We assessed the clinical performance of this medium combined with Vitek mass spectrometry (MS) matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) technology for the isolation and identification of NTM in a prospective multicenter study, including 15 laboratories (24 hospitals). A total of 2,567 samples from patients with suspected NTM infection were analyzed (1,782 sputa, 434 bronchial aspirates, 200 bronchoalveolar lavage samples, 34 bronchial lavage samples, and 117 other samples). A total of 220 samples (8.6%) were positive with existing laboratory methods against 330 with NTM Elite agar (12.8%). Using the combination of both methods, 437 isolates of NTM were detected in 400 positive samples (15.6% of samples). In total, 140 samples of the standard procedures (SP) and 98 of the NTM Elite agar were contaminated. NTM Elite agar showed a higher performance for rapidly growing mycobacteria (RGM) species than SP (7% versus 3%, P < 0.001). A trend has been noted for the Mycobacterium avium complex (4% with SP versus 3% with NTM Elite agar, P = 0.06). The time to positivity was similar (P = 0.13) between groups. However, the time to positivity was significantly shorter for the RGM in subgroup analysis (7 days with NTM and 6 days with SP, P = 0.01). NTM Elite agar has been shown to be useful for the recovery of NTM species, especially for the RGM. Using NTM Elite agar + Vitek MS system in combination with SP increases the number of NTM isolated from clinical samples.
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Affiliation(s)
| | - Laura Barrado
- Department of Clinical Microbiology, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain
| | - Paula Lopez-Roa
- Department of Microbiology, Hospital Universitario, Madrid, Spain
| | - Juana Cacho
- Department of Microbiology, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Diego Domingo
- Department of Microbiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Sara Hernandez
- Microbiology Laboratory, Hospital Severo Ochoa, Leganés, Madrid, Spain
| | | | - Maria Rosario Millan
- Department of Microbiology, H.U. Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | | | - Maria-Jesus Ruiz-Serrano
- Department of Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBERES-CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Santiago Salso
- Clinical Laboratory, UR Salud. Paseo de Europa, San Sebastián de los Reyes, Madrid, Spain
| | - Maria Simon
- Department of Microbiology and Parasitology, Hospital Central de la Defensa Gomez Ulla, Madrid, Spain
| | - Marta Tato
- Department of Microbiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Carlos Toro
- Department of Microbiology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- CIBERINFEC-CIBER de Enfermedades Infecciosas, Madrid, Spain
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Alarcón-Linares ME, Moreno-Docón A, Pérez-Serna L, Camacho J, Rodriguez DS, Gutiérrez-Martín ML, Broncano-Lavado A, Echevarria JE, Cabrerizo M, Fernández-García MD. Rare Recombinant GI.5[P4] Norovirus That Caused a Large Foodborne Outbreak of Gastroenteritis in a Hotel in Spain in 2021. Microbiol Spectr 2023; 11:e0485722. [PMID: 36809021 PMCID: PMC10100975 DOI: 10.1128/spectrum.04857-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 11/26/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023] Open
Abstract
Noroviruses are among the most important causes of acute gastroenteritis (AGE). In summer 2021, a large outbreak of norovirus infections affecting 163 patients, including 15 norovirus-confirmed food handlers, occurred in a hotel in Murcia in southeast Spain. A rare GI.5[P4] norovirus strain was identified as the cause of the outbreak. The epidemiological investigation determined that norovirus transmission might have been initiated through an infected food handler. The food safety inspection found that some symptomatic food handlers continued working during illness. Molecular investigation with whole-genome and ORF1 sequencing provided enhanced genetic discrimination over ORF2 sequencing alone and enabled differentiation of the GI.5[P4] strains into separate subclusters, suggesting different chains of transmission. These recombinant viruses have been identified circulating globally over the last 5 years, warranting further global surveillance. IMPORTANCE Due to the large genetic diversity of noroviruses, it is important to enhance the discriminatory power of typing techniques to differentiate strains when investigating outbreaks and elucidating transmission chains. This study highlights the importance of (i) using whole-genome sequencing to ensure genetic differentiation of GI noroviruses to track chains of transmission during outbreak investigations and (ii) the adherence of symptomatic food handlers to work exclusion rules and strict hand hygiene practices. To our knowledge, this study provides the first full-length genome sequences of GI.5[P4] strains apart from the prototype strain.
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Affiliation(s)
| | - Antonio Moreno-Docón
- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- IMIB—Arrixaca, Universidad de Murcia, Murcia, Spain
| | | | - Juan Camacho
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Antonio Broncano-Lavado
- Instituto de Investigación Sanitaria—Fundación Jiménez Díaz Hospital Universitario, Universidad Autónoma de Madrid (IIS-FJD, UAM), Madrid, Spain
| | - Juan-Emilio Echevarria
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María Cabrerizo
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María D. Fernández-García
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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