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Barceló IM, Escobar-Salom M, Cabot G, Perelló-Bauzà P, Jordana-Lluch E, Taltavull B, Torrens G, Rojo-Molinero E, Zamorano L, Pérez A, Oliver A, Juan C. Transferable AmpCs in Klebsiella pneumoniae: interplay with peptidoglycan recycling, mechanisms of hyperproduction, and virulence implications. Antimicrob Agents Chemother 2024; 68:e0131523. [PMID: 38517189 PMCID: PMC11064642 DOI: 10.1128/aac.01315-23] [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: 10/09/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Chromosomal and transferable AmpC β-lactamases represent top resistance mechanisms in different gram-negatives, but knowledge regarding the latter, mostly concerning regulation and virulence-related implications, is far from being complete. To fill this gap, we used Klebsiella pneumoniae (KP) and two different plasmid-encoded AmpCs [DHA-1 (AmpR regulator linked, inducible) and CMY-2 (constitutive)] as models to perform a study in which we show that blockade of peptidoglycan recycling through AmpG permease inactivation abolished DHA-1 inducibility but did not affect CMY-2 production and neither did it alter KP pathogenic behavior. Moreover, whereas regular production of both AmpC-type enzymes did not attenuate KP virulence, when blaDHA-1 was expressed in an ampG-defective mutant, Galleria mellonella killing was significantly (but not drastically) attenuated. Spontaneous DHA-1 hyperproducer mutants were readily obtained in vitro, showing slight or insignificant virulence attenuations together with high-level resistance to β-lactams only mildly affected by basal production (e.g., ceftazidime, ceftolozane/tazobactam). By analyzing diverse DHA-1-harboring clinical KP strains, we demonstrate that the natural selection of these hyperproducers is not exceptional (>10% of the collection), whereas mutational inactivation of the typical AmpC hyperproduction-related gene mpl was the most frequent underlying mechanism. The potential silent dissemination of this kind of strains, for which an important fitness cost-related contention barrier does not seem to exist, is envisaged as a neglected threat for most β-lactams effectiveness, including recently introduced combinations. Analyzing whether this phenomenon is applicable to other transferable β-lactamases and species as well as determining the levels of conferred resistance poses an essential topic to be addressed.IMPORTANCEAlthough there is solid knowledge about the regulation of transferable and especially chromosomal AmpC β-lactamases in Enterobacterales, there are still gaps to fill, mainly related to regulatory mechanisms and virulence interplays of the former. This work addresses them using Klebsiella pneumoniae as model, delving into a barely explored conception: the acquisition of a plasmid-encoded inducible AmpC-type enzyme whose production can be increased through selection of chromosomal mutations, entailing dramatically increased resistance compared to basal expression but minor associated virulence costs. Accordingly, we demonstrate that clinical K. pneumoniae DHA-1 hyperproducer strains are not exceptional. Through this study, we warn for the first time that this phenomenon may be a neglected new threat for β-lactams effectiveness (including some recently introduced ones) silently spreading in the clinical context, not only in K. pneumoniae but potentially also in other pathogens. These facts must be carefully considered in order to design future resistance-preventive strategies.
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Affiliation(s)
- Isabel M. Barceló
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Maria Escobar-Salom
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Gabriel Cabot
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pau Perelló-Bauzà
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Elena Jordana-Lluch
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Biel Taltavull
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Gabriel Torrens
- Department of Molecular Biology and Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå Centre for Microbial Research (UCMR), Umeå University, Umeå, Sweden
| | - Estrella Rojo-Molinero
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Laura Zamorano
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Astrid Pérez
- National Center for Microbiology, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Antonio Oliver
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Carlos Juan
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Microbiology Department, University Hospital Son Espases (HUSE), Palma, Spain
- Centro de Investigación Biomédica en Red, Área Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Cerón-Pisa N, Shafiek H, Martín-Medina A, Verdú J, Jordana-Lluch E, Escobar-Salom M, Barceló IM, López-Causapé C, Oliver A, Juan C, Iglesias A, Cosío BG. Effects of Inhaled Corticosteroids on the Innate Immunological Response to Pseudomonas aeruginosa Infection in Patients with COPD. Int J Mol Sci 2022; 23:ijms23158127. [PMID: 35897707 PMCID: PMC9332726 DOI: 10.3390/ijms23158127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/16/2022] Open
Abstract
Inhaled corticosteroids (ICS) use is associated with an increased risk of Pseudomonas aeruginosa (PA) infection in patients with COPD. We aimed to evaluate the effects of ICS on alveolar macrophages in response to PA in COPD patients with and without baseline ICS treatment (COPD and COPD + ICS, respectively) as well as smoker and nonsmoker controls. To do so, cells were infected with PA and cotreated with budesonide (BUD) or fluticasone propionate (FLU). The analysis of NF-κB and c-jun activity revealed a significant increase in both factors in response to PA cotreated with BUD/FLU in smokers but not in COPD or COPD + ICS patients when compared with PA infection alone. The expression of Toll-like receptor 2 (TLR2) and the transcription factor c-jun were induced upon PA infection in nonsmokers only. Moreover, in the smoker and COPD groups, there was a significant increase in TLR2 and a decrease in c-jun expression when treated with BUD/FLU after PA infection, which were not observed in COPD + ICS patients. Therefore, the chronic use of ICS seemingly makes the macrophages tolerant to BUD/FLU stimulation compared with those from patients not treated with ICS, promoting an impaired recognition of PA and activity of alveolar macrophages in terms of altered expression of TLR2 and cytokine production, which could explain the increased risk of PA infection in COPD patients under ICS treatment.
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Affiliation(s)
- Noemi Cerón-Pisa
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
| | - Hanaa Shafiek
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt;
| | - Aina Martín-Medina
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
| | - Javier Verdú
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Department of Respiratory Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Elena Jordana-Lluch
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Maria Escobar-Salom
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Isabel M. Barceló
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Carla López-Causapé
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Antonio Oliver
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Carlos Juan
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Amanda Iglesias
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), 28029 Madrid, Spain
- Correspondence: (A.I.); (B.G.C.); Tel.: +34-871-205-050 (ext. 64521) (A.I. & B.G.C.)
| | - Borja G. Cosío
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Department of Respiratory Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), 28029 Madrid, Spain
- Correspondence: (A.I.); (B.G.C.); Tel.: +34-871-205-050 (ext. 64521) (A.I. & B.G.C.)
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Torrens G, Escobar-Salom M, Oliver A, Juan C. Activity of mammalian peptidoglycan-targeting immunity against Pseudomonas aeruginosa. J Med Microbiol 2020; 69:492-504. [PMID: 32427563 DOI: 10.1099/jmm.0.001167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pseudomonas aeruginosa is one of the most important opportunistic pathogens, whose clinical relevance is not only due to the high morbidity/mortality of the infections caused, but also to its striking capacity for antibiotic resistance development. In the current scenario of a shortage of effective antipseudomonal drugs, it is essential to have thorough knowledge of the pathogen's biology from all sides, so as to find weak points for drug development. Obviously, one of these points could be the peptidoglycan, given its essential role for cell viability. Meanwhile, immune weapons targeting this structure could constitute an excellent model to be taken advantage of in order to design new therapeutic strategies. In this context, this review gathers all the information regarding the activity of mammalian peptidoglycan-targeting innate immunity (namely lysozyme and peptidoglycan recognition proteins), specifically against P. aeruginosa. All the published studies were considered, from both in vitro and in vivo fields, including works that envisage these weapons as options not only to potentiate their innate effects within the host or for use as exogenously administered treatments, but also harnessing their inflammatory and immune regulatory capacity to finally reduce damage in the patient. Altogether, this review has the objective of anticipating and discussing whether these innate immune resources, in combination or not with other drugs attacking certain P. aeruginosa targets leading to its increased sensitization, could be valid therapeutic antipseudomonal allies.
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Affiliation(s)
- Gabriel Torrens
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Maria Escobar-Salom
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Torrens G, Barceló IM, Pérez-Gallego M, Escobar-Salom M, Tur-Gracia S, Munar-Bestard M, González-Nicolau MDM, Cabrera-Venegas YJ, Rigo-Rumbos EN, Cabot G, López-Causapé C, Rojo-Molinero E, Oliver A, Juan C. Publisher Correction: Profiling the susceptibility of Pseudomonas aeruginosa strains from acute and chronic infections to cell-wall-targeting immune proteins. Sci Rep 2020; 10:4356. [PMID: 32132557 PMCID: PMC7055294 DOI: 10.1038/s41598-020-60494-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Gabriel Torrens
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Isabel M Barceló
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Marcelo Pérez-Gallego
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Maria Escobar-Salom
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Sara Tur-Gracia
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Marta Munar-Bestard
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - María Del Mar González-Nicolau
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Yoandy José Cabrera-Venegas
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Estefany Nayarith Rigo-Rumbos
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Gabriel Cabot
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Carla López-Causapé
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Estrella Rojo-Molinero
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Carlos Juan
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain.
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Torrens G, Barceló IM, Pérez-Gallego M, Escobar-Salom M, Tur-Gracia S, Munar-Bestard M, González-Nicolau MDM, Cabrera-Venegas YJ, Rigo-Rumbos EN, Cabot G, López-Causapé C, Rojo-Molinero E, Oliver A, Juan C. Profiling the susceptibility of Pseudomonas aeruginosa strains from acute and chronic infections to cell-wall-targeting immune proteins. Sci Rep 2019; 9:3575. [PMID: 30837659 PMCID: PMC6401076 DOI: 10.1038/s41598-019-40440-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/06/2019] [Indexed: 02/06/2023] Open
Abstract
In the current scenario of high antibiotic resistance, the search for therapeutic options against Pseudomonas aeruginosa must be approached from different perspectives: cell-wall biology as source of bacterial weak points and our immune system as source of weapons. Our recent study suggests that once the permeability barrier has been overcome, the activity of our cell-wall-targeting immune proteins is notably enhanced, more in mutants with impaired peptidoglycan recycling. The present work aims at analyzing the activity of these proteins [lysozyme and Peptidoglycan-Recognition-Proteins (PGLYRPs)], alone or with a permeabilizer (subinhibitory colistin) in clinical strains, along with other features related to the cell-wall. We compared the most relevant and complementary scenarios: acute (bacteremia) and chronic infections [early/late isolates from lungs of cystic fibrosis (CF) patients]. Although a low activity of lysozyme/PGLYRPs per se (except punctual highly susceptible strains) was found, the colistin addition significantly increased their activity regardless of the strains’ colistin resistance levels. Our results show increased susceptibility in late CF isolates, suggesting that CF adaptation renders P. aeruginosa more vulnerable to proteins targeting the cell-wall. Thus, our work suggests that attacking some P. aeruginosa cell-wall biology-related elements to increase the activity of our innate weapons could be a promising therapeutic strategy.
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Affiliation(s)
- Gabriel Torrens
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Isabel M Barceló
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Marcelo Pérez-Gallego
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Maria Escobar-Salom
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Sara Tur-Gracia
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Marta Munar-Bestard
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - María Del Mar González-Nicolau
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Yoandy José Cabrera-Venegas
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Estefany Nayarith Rigo-Rumbos
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Gabriel Cabot
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Carla López-Causapé
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Estrella Rojo-Molinero
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain
| | - Carlos Juan
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitari Son Espases-Institut de Investigació Sanitària de Balears (IdISBa), Palma, Spain.
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