1
|
Cun WY, Keller PA, Pyne SG. Synthesis of 7α-Methoxy-7-(4-phenyl-1 H-1,2,3-triazol-1-yl)acetamino-3'-arylthio-cephalosporic Acid Derivatives from 7-Aminocephalosporic Acid. Molecules 2023; 28:7338. [PMID: 37959756 PMCID: PMC10650751 DOI: 10.3390/molecules28217338] [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: 10/12/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this project was to develop a synthetic protocol for the preparation of a cephamycin scaffold that would readily allow the synthesis of its analogues with variations at the C-7 amino group and the C-3' position. We also aimed to develop a method that avoided the use of toxic and potentially explosive diphenyldiazomethane. These aims were achieved via the synthesis of the novel α-bromo acetamide 18 which allowed functionalization at the α-bromo acetamide position by azide and then the introduction of a 4-phenyl-1H-1,2,3-triazol-1-yl moiety via a Cu(I)-catalysed azide-alkyne cycloaddition reaction with phenylacetylene. Palladium-catalyzed arylthioallylation reactions then allowed the introduction of 3'-arylthiol substituents. We also report for the first time the synthesis of the 4-methoxybenzyl ester of (6R,7S)-3-[(acetyloxy)methyl]-7-amino-7-methoxy-8-oxo-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid and the use of diphenyl trichloroacetimidate, instead of diphenyldiazomethane, and 4-methoxybenzyl trichloroacetimidate to prepare related 4-methoxybenzyl esters. The chemistry described, and several of the synthetic intermediates reported here, are potentially valuable methods and scaffolds, respectively, for further development of β-lactam antibiotics.
Collapse
Affiliation(s)
| | | | - Stephen G. Pyne
- School of Chemistry and Molecular Bioscience, Molecular Horizons Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia; (W.Y.C.); (P.A.K.)
| |
Collapse
|
2
|
Hayakawa K, Matsumura Y, Uemura K, Tsuzuki S, Sakurai A, Tanizaki R, Shinohara K, Hashimoto T, Hase R, Matono T, Kato H, Mawatari M, Hara H, Hamada Y, Saito S, Ohmagari N, Doi Y. Effectiveness of cefmetazole versus meropenem for invasive urinary tract infections caused by extended-spectrum β-lactamase-producing Escherichia coli. Antimicrob Agents Chemother 2023; 67:e0051023. [PMID: 37702483 PMCID: PMC10583665 DOI: 10.1128/aac.00510-23] [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: 04/21/2023] [Accepted: 07/12/2023] [Indexed: 09/14/2023] Open
Abstract
Cefmetazole is active against extended-spectrum β-lactamase-producing Escherichia coli (ESBLEC) and is a potential candidate for carbapenem-sparing therapy. This multicenter, observational study included patients hospitalized for invasive urinary tract infection due to ESBLEC between March 2020 and November 2021 at 10 facilities in Japan, for whom either cefmetazole or meropenem was initiated as a definitive therapy within 96 h of culture collection and continued for at least 3 d. Outcomes included clinical and microbiological effectiveness, recurrence within 28 d, and all-cause mortality (14 d, 30 d, in-hospital). Outcomes were adjusted for the inverse probability of propensity scores for receiving cefmetazole or meropenem. Eighty-one and forty-six patients were included in the cefmetazole and meropenem groups, respectively. Bacteremia accounted for 43% of the cefmetazole group, and 59% of the meropenem group. The crude clinical effectiveness, 14 d, 30 d, and in-hospital mortality for patients in the cefmetazole and meropenem groups were 96.1% vs 90.9%, 0% vs 2.3%, 0% vs 12.5%, and 2.6% vs 13.3%, respectively. After propensity score adjustment, clinical effectiveness, the risk of in-hospital mortality, and the risk of recurrence were similar between the two groups (P = 0.54, P = 0.10, and P = 0.79, respectively). In all cases with available data (cefmetazole : n = 61, meropenem : n = 22), both drugs were microbiologically effective. In all isolates, bla CTX-M was detected as the extended-spectrum β-lactamase gene. The predominant CTX-M subtype was CTX-M-27 (47.6%). Cefmetazole showed clinical and bacteriological effectiveness comparable to meropenem against invasive urinary tract infection due to ESBLECs.
Collapse
Affiliation(s)
- Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kohei Uemura
- Interfaculty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan
| | - Shinya Tsuzuki
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Aki Sakurai
- Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Ryutaro Tanizaki
- Department of Internal Medicine and General Medicine, Ise Municipal General Hospital, Mie, Japan
| | - Koh Shinohara
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Ryota Hase
- Department of Infectious Diseases, Japanese Red Cross Narita Hospital, Chiba, Japan
| | - Takashi Matono
- Department of Infectious Diseases, Aso Iizuka Hospital, Fukuoka, Japan
| | - Hideaki Kato
- Infection Prevention and Control Department, Yokohama City University Hospital, Kanagawa, Japan
| | - Momoko Mawatari
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroshi Hara
- Department of pharmacy, Yokohama Brain and Spine Center, Kanagawa, Japan
| | - Yukihiro Hamada
- Department of pharmacy, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Sho Saito
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yohei Doi
- Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Aichi, Japan
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Kuwana T, Yamaguchi J, Kinoshita K, Hori S, Ihara S, Taniguchi T. Successful de-escalation antibiotic therapy using cephamycins for sepsis caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae bacteremia: A sequential 25-case series. Open Med (Wars) 2020; 15:782-786. [PMID: 33336036 PMCID: PMC7711866 DOI: 10.1515/med-2020-0103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 01/10/2023] Open
Abstract
Carbapenems are frequently used to treat infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), but carbapenem-resistant Enterobacteriaceae bacteria are a clinical concern. Although cephamycins (cefmetazole; CMZ) have been shown to be effective against mild cases of ESBL-E infection, data on their use for severe ESBL-E infections with sepsis or septic shock remain scarce. Herein, we discuss a de-escalation therapy to CMZ that could be used after empiric antibiotic therapy in ICU patients with sepsis or septic shock caused by ESBL-E bacteremia. A sequence of 25 cases diagnosed with sepsis or septic shock caused by ESBL-E bacteria was evaluated. The attending infectious disease specialist physicians selected the antibiotics and decided the de-escalation timing. The median SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) severity scores were 8 and 30; the rate of septic shock was 60%. Infections originated most frequently with urinary tract infection (UTI) (56%) and Escherichia coli (85%). Eleven patients were de-escalated to CMZ after vital signs were stable, and all survived. No patients died of UTI regardless of with or without de-escalation. The median timing of de-escalation antibiotic therapy after admission was 4 days (range, 3–6 days). At the time of de-escalation, the median SOFA score fell from 8 to 5, the median APACHE II score from 28 to 22, and the rate of septic shock from 55% to 0%. We conclude that for sepsis in UTI caused by ESBL-E bacteremia, de-escalation therapy from broad-spectrum antibiotics to CMZ is a potential treatment option when vital signs are stable.
Collapse
Affiliation(s)
- Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Hori
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shingo Ihara
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tetsuya Taniguchi
- Division of Mathematics, Department of Liberal Arts, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| |
Collapse
|
4
|
Hagiya H, Sugawara Y, Tsutsumi Y, Akeda Y, Yamamoto N, Sakamoto N, Shanmugakani RK, Abe R, Takeuchi D, Nishi I, Ishii Y, Hamada S, Tomono K. In Vitro Efficacy of Meropenem-Cefmetazole Combination Therapy against New Delhi Metallo-β-lactamase-producing Enterobacteriaceae. Int J Antimicrob Agents 2020; 55:105905. [PMID: 31991221 DOI: 10.1016/j.ijantimicag.2020.105905] [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: 08/06/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Limited treatment options complicate management of infections with New Delhi metallo-β-lactamase (NDM)-producing organisms. The efficacy of combination therapy with meropenem (MEM) and cefmetazole (CMZ) was assessed against NDM-producing Enterobacteriaceae. MATERIALS AND METHODS Twelve Escherichia coli clinical isolates harbouring blaNDM-1 and a positive control E. coli BAA-2469 harbouring blaNDM-1 were studied. Minimum inhibitory concentrations (MICs) of MEM, ertapenem (ERT) and CMZ were determined by broth microdilution. Checkerboard and time-kill assays were performed to confirm the in vitro efficacy of the MEM/CMZ combination. Scanning electron microscopy, kinetic studies and whole-genome sequence analysis were used to determine the antimicrobial resistance mechanisms. RESULTS MICs of MEM, ERT and CMZ in monotherapy ranged from 8 to 32, 16 to 128, and 32 to 512 µg/mL, respectively. In the checkerboard assay, MEM/ERT resulted in no synergy, whereas MEM/CMZ showed a synergistic effect in all the tested isolates. Furthermore, the MIC of MEM in combination decreased by 2- to 8-fold compared with that of MEM alone. The time-kill study revealed a bactericidal effect in 4 of 13 isolates at 24 h. Scanning electron microscopy showed spheroidisation of the bacterial cell in the MEM/CMZ combination; this was not observed in single antibiotic conditions. Kinetic studies indicated CMZ was a better antagonist for NDM-1 than ERT. Whole-genome sequence analysis did not reveal any explainable differences between isolates susceptible and those non-susceptible to combination therapy. CONCLUSION In vitro studies showed the potential effectiveness of MEM/CMZ combination therapy against NDM-producing organisms.
Collapse
Affiliation(s)
- Hideharu Hagiya
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan; Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Yo Sugawara
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
| | - Yuko Tsutsumi
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan; Meiji Seika Pharma Co., Ltd, Pharmaceutical Research Center, Yokohama, Japan.
| | - Yukihiro Akeda
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan; Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
| | - Norihisa Yamamoto
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Noriko Sakamoto
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
| | - Rathina Kumar Shanmugakani
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Ryuichiro Abe
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan. abyaryu-@hotmail.co.jp
| | - Dan Takeuchi
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
| | - Isao Nishi
- Laboratory for Clinical Investigation, Osaka University Hospital, Osaka, Japan.
| | - Yoshikazu Ishii
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan.
| | - Shigeyuki Hamada
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
| | - Kazunori Tomono
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan.
| |
Collapse
|
5
|
Araki K, Fukuoka K, Higuchi H, Aizawa Y, Horikoshi Y. Cefmetazole for extended-spectrum β-lactamase-producing Enterobacteriaceae in pediatric pyelonephritis. Pediatr Int 2019; 61:572-577. [PMID: 30908807 DOI: 10.1111/ped.13847] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/18/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pyelonephritis caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is an urgent problem in pediatrics. Although carbapenem is the standard therapy for infections caused by ESBL-producing Enterobacteriaceae, some cephamycins, including cefmetazole, are stable against hydrolysis by ESBL. There are few reports, however, on the use of cefmetazole in children. The aim of this study was to evaluate the therapeutic effect of cefmetazole in pediatric pyelonephritis caused by ESBL-producing Enterobacteriaceae. METHODS Children with pyelonephritis caused by ESBL-producing Enterobacteriaceae were enrolled between April 2010 and November 2016 at Tokyo Metropolitan Children's Medical Center. Presence of ESBL was tested for using the disk diffusion method. Medical records were reviewed for a past history of bacterial infection. The outcomes were clinical cure rate at 4 weeks and the duration of therapy in the cefmetazole and non-cefmetazole groups. RESULTS Fifty-five patients met the criteria for pyelonephritis caused by ESBL-producing Enterobacteriaceae. The most common causative organisms were Escherichia coli (n = 51; 92.7%), Klebsiella pneumoniae (n = 3; 5.5%), and K. oxytoca (n = 1; 1.8%). Thirty-six and 19 patients were treated with cefmetazole and with other antibiotics as definitive therapy, respectively. There was no difference in the clinical cure rate (86.1% vs 89.5%; P = 0.72) or duration of therapy (median, 7.0 vs 7.0 days; P = 0.73) between the cefmetazole and non-cefmetazole groups. CONCLUSIONS Cefmetazole was not inferior to the other antibiotics in the treatment of pyelonephritis caused by ESBL-producing Enterobacteriaceae in children. Cefmetazole is a valuable therapeutic alternative to carbapenems for treating pyelonephritis caused by ESBL-producing Enterobacteriaceae.
Collapse
Affiliation(s)
- Kotaro Araki
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kahoru Fukuoka
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Higuchi
- Division of Microbiology, Department of Laboratory, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuta Aizawa
- Department of Pediatrics, Niigata University, Niigata City, Japan
| | - Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| |
Collapse
|
6
|
Hagiya H, Aoki K, Akeda Y, Yamamoto N, Shanmugakani RK, Ishii Y, Tomono K. In Vitro Effectiveness of Meropenem and Cefmetazole Combination Treatment Against KPC-2-Producing Enterobacteriaceae. Microb Drug Resist 2019; 25:839-845. [PMID: 30835635 DOI: 10.1089/mdr.2018.0397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/08/2023] Open
Abstract
Purpose: Optimal treatment regimens are yet to be established for carbapenemase-producing Enterobacteriaceae (CPE). We assessed the in vitro efficacy of meropenem (MEM) and cefmetazole (CMZ) combination treatment against blaKPC-2-positive Enterobacteriaceae, in comparison with that of double-carbapenem therapy using ertapenem (ERT). Materials and Methods: We performed checkerboard assay for 10 blaKPC-2-positive clinical isolates and Klebsiella pneumoniae BAA-1705 (possessing blaKPC-2), with synergistic effect being defined by a fractional inhibitory concentration index of ≤0.5. Subsequently, we conducted time-kill assays using K. pneumoniae BAA-1705 with an initial inoculum of 104-107 colony forming unit (CFU)/mL. Bactericidal effect was defined as the reduction of initial bacterial count by ≥103 CFU/mL in 24 hr. Finally, we applied scanning electron microscopy to observe morphological changes induced by the combination of MEM and CMZ. Results: Checkerboard assays revealed a synergistic effect in 7 out of 11 blaKPC-2 -positive Enterobacteriaceae when the MEM and CMZ combination was used, and no effect when the MEM and ERT combination was used. The minimum inhibitory concentration of MEM decreased 4-8-fold when combined with CMZ. Time-kill assays with an initial inoculum of 5 × 105 CFU/mL revealed regrowth under the combination of MEM and ERT (0.25 × minimum inhibitory concentration [MIC] each), whereas the combination of 0.25 × MIC each of MEM and CMZ exhibited bactericidal effect. Scanning electron microscopy results demonstrated that the combination of 0.5 × MIC MEM and 0.5 × MIC CMZ facilitated bacterial cell lysis compared with each antibiotic alone. Conclusion: The combination therapy using MEM and CMZ potentially has bactericidal effect against KPC-producing Enterobacteriaceae.
Collapse
Affiliation(s)
- Hideharu Hagiya
- 1 Department of Infection Control and Prevention, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kotaro Aoki
- 2 Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Yukihiro Akeda
- 1 Department of Infection Control and Prevention, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Norihisa Yamamoto
- 1 Department of Infection Control and Prevention, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Rathina Kumar Shanmugakani
- 1 Department of Infection Control and Prevention, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoshikazu Ishii
- 2 Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Kazunori Tomono
- 1 Department of Infection Control and Prevention, Graduate School of Medicine, Osaka University, Osaka, Japan
| |
Collapse
|
7
|
Lee CH, Chen IL, Li CC, Chien CC. Clinical benefit of ertapenem compared to flomoxef for the treatment of cefotaxime-resistant Enterobacteriaceae bacteremia. Infect Drug Resist 2018; 11:257-266. [PMID: 29503575 PMCID: PMC5826091 DOI: 10.2147/idr.s146923] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Indexed: 12/15/2022] Open
Abstract
Objectives Cefotaxime-resistant Enterobacteriaceae (CE) infections are intractable, with limited treatment options. Though carbapenems are frequently prescribed for CE infections, the emergence of carbapenem-resistant Enterobacteriaceae is of huge concern. Flomoxef is effective against CE in vitro, and some clinical data on its demonstrated effectiveness against CE bloodstream infections (BSIs) exists. Patients and methods We conducted a retrospective study on adults with BSI caused by flomoxef-susceptible CE to investigate the efficacy of flomoxef compared with that of ertapenem. The outcome was evaluated with propensity score-based matching and logistic regression analysis. Results Demographic and clinical characteristics of patients treated with flomoxef (n = 58) or ertapenem (n = 188) were compared. In the multivariate analysis, severe sepsis (adjusted odds ratio [AOR] = 3.84; 95% confidence interval [CI], 1.16–12.78; p = 0.03), high BSI mortality score (AOR = 5.59; 95% CI, 2.37–13.21; p < 0.01), ultimately or rapidly fatal comorbidity (AOR = 10.60; 95% CI, 3.43–32.75; p < 0.01), and pneumonia (AOR = 10.11; 95% CI, 3.43–29.81; p < 0.01) were independently associated with 28-day mortality. Using propensity scores, 58 flomoxef-treated patients were matched to 116 ertapenem-treated patients. There were no intergroup differences in BSI severity, comorbidity, or BSI sources. The 28-day mortality rates (20.7% vs 13.8%, p = 0.28) did not differ significantly. However, hospitalization length was shorter in the ertapenem group (10.2 ± 8.5 vs. 14.6 ± 9.4 days, p < 0.01). Conclusion Although similar outcomes were observed between the groups, ertapenem therapy was associated with a shorter hospitalization time in adults after CE BSI.
Collapse
Affiliation(s)
- Chen-Hsiang Lee
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial, Hospital.,Chang Gung University, College of Medicine
| | | | - Chia-Chin Li
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| |
Collapse
|