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Pinchera B, Carrano R, Schettino E, D'Agostino A, Trucillo E, Cuccurullo F, Salemi F, Piccione A, Gentile I. Urinary tract infections in kidney transplant patients admitted to hospital: A real-life experience. World J Transplant 2025; 15:99554. [DOI: 10.5500/wjt.v15.i2.99554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 11/07/2024] [Accepted: 11/28/2024] [Indexed: 02/21/2025] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) in kidney transplant patients are a challenge.
AIM To evaluate epidemiology, clinical status, therapeutic management, and clinical outcome of kidney transplant patients in a university hospital for UTI.
METHODS We conducted a retrospective observational study, enrolling all kidney transplant patients hospitalized for UTI, with the objective to evaluate the epidemiology, clinical status, therapeutic management, and clinical outcome of kidney transplant patients.
RESULTS From our real-life experience, infection with multidrug-resistant germs was confirmed as a risk factor for the severe evolution of the infection. At the same time, the re-evaluation of immunosuppressive therapy could be an important therapeutic strategy in the course of infection.
CONCLUSION Prompt initiation of empiric antibiotic therapy upon initiation of microbiological investigations may reduce the risk of severe infection progression.
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Affiliation(s)
- Biagio Pinchera
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples 80131, Italy
| | - Rosa Carrano
- Section of Nephrology, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Elisa Schettino
- Section of Nephrology, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Alessia D'Agostino
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples 80131, Italy
| | - Emilia Trucillo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples 80131, Italy
| | - Federica Cuccurullo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples 80131, Italy
| | - Fabrizio Salemi
- Section of Nephrology, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Amerigo Piccione
- Section of Nephrology, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples 80131, Italy
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Shettar SR, Sumana MN, Shetty MS, Maheshwarappa YD, Reddy RG, Srinivasan A, P VD, Kalyatanda G, S C SS. Case Report: Management of recurrent UTI with tigecycline in a kidney transplant recipient. FRONTIERS IN TRANSPLANTATION 2025; 3:1496702. [PMID: 40040669 PMCID: PMC11876407 DOI: 10.3389/frtra.2024.1496702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Accepted: 12/26/2024] [Indexed: 03/06/2025]
Abstract
This case report describes a 37-year-old man who underwent renal transplantation and subsequently developed complicated recurrent urinary tract infections (UTIs) caused by multidrug-resistant (MDR) Klebsiella pneumoniae. Despite initial treatment with fosfomycin and meropenem, the patient experienced persistent UTIs, leading to multiple hospitalizations. The management of these recurrent infections eventually required the use of tigecycline. Although tigecycline is not typically considered a urinary antibiotic owing to its limited urinary excretion, it was successfully employed in this case to manage the recurrent infections. The patient was treated with tigecycline for several episodes of UTI, which provided a crucial therapeutic option in the context of antibiotic resistance. This case underscores the challenges of managing recurrent MDR UTIs in immunocompromised patients and highlights tigecycline as an effective treatment strategy when standard therapies fail.
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Affiliation(s)
- Supreeta R. Shettar
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | | | - Manjunath S. Shetty
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | | | - Raghukanth G. Reddy
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | - Asha Srinivasan
- Division of Nanoscience and Technology, School of Life Sciences, JSS Academy of Higher Education and Research, Mysuru, India
| | - Vamshi Dharan P
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | - Gautam Kalyatanda
- Division of Infectious Disease and Global Medicine, University of Florida, Gainesville, FL, United States
| | - Shruthi Shree S C
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
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Shettar SR, Sumana MN, Shetty MS, Maheshwarappa YD, Raghukanth RG, Srinivasan A, Vamshi DP, Kalyatanda G, Veerabhadra SGS, Chinchana SE. Case Report: Management of a case of multidrug-resistant Klebsiella pneumoniae infection in a second-kidney transplant patient. FRONTIERS IN TRANSPLANTATION 2025; 3:1494016. [PMID: 39896133 PMCID: PMC11782155 DOI: 10.3389/frtra.2024.1494016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Accepted: 12/09/2024] [Indexed: 02/04/2025]
Abstract
This case report on recurrent urinary tract infections (UTIs) caused by multidrug-resistant (MDR) Klebsiella pneumoniae in a post-renal transplant patient underscores the significant clinical challenge of managing MDR infections in immunocompromised individuals, particularly in the context of renal transplantation. The patient was treated with an extended infusion of meropenem, which offers prolonged drug exposure and enhances bactericidal activity against MDR pathogens. This approach is critical in overcoming the resistance mechanisms inherent to Klebsiella pneumoniae, thereby improving the likelihood of therapeutic success. The findings presented here highlight the potential efficacy of extended meropenem infusion in treating MDR infections, providing a valuable therapeutic option for clinicians facing similar cases. This report contributes to the growing evidence supporting advanced antibiotic administration techniques in managing complicated urinary tract infections in transplant in resource limited countries.
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Affiliation(s)
- Supreeta R. Shettar
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | | | - Manjunath S. Shetty
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | | | - Reddy G. Raghukanth
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | - Asha Srinivasan
- Department of Nanoscience and Technology, School of Life Sciences, JSS Academy of Higher Education and Research, Mysuru, India
| | - Dharan P. Vamshi
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
| | - Gautam Kalyatanda
- Division of Infectious Disease and Global Medicine, University of Florida, Gainesville, FL, United States
| | - Swamy G. S. Veerabhadra
- JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
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Pinchera B, Trucillo E, D’Agostino A, Gentile I. Urinary Tract Infections in Kidney Transplant Patients: An Open Challenge-Update on Epidemiology, Risk Factors and Management. Microorganisms 2024; 12:2217. [PMID: 39597604 PMCID: PMC11596552 DOI: 10.3390/microorganisms12112217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 10/26/2024] [Accepted: 10/28/2024] [Indexed: 11/29/2024] Open
Abstract
Urinary tract infections are one of the main complications in kidney transplant patients, with a significant impact on graft function and survival. In fact, it is estimated that up to 74% of kidney transplant patients experience at least one episode of UTIs in the first year after transplantation, with an increased risk of graft loss and an increased risk of mortality. Several risk factors have been identified, such as female gender, old age, diabetes mellitus, immunosuppression, pre-transplant UTIs, urinary tract abnormalities, and prolonged dialysis. The worsening burden of antimicrobial resistance is also in itself a risk factor and a major complication in evolution and management. The management of prophylaxis, asymptomatic bacteriuria, and UTIs is still an open challenge, with some points to be clarified. Faced with such scenarios, our review aimed to evaluate the current epidemiology, examine the risk factors, and consider all the possibilities and methods of management, giving a current view and evaluation of the topic.
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Affiliation(s)
- Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples “Federico II”, Via Sergio Pansini 5, 80131 Naples, Italy; (E.T.); (A.D.); (I.G.)
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Chen KD, Chen W, Zhang Q, Li Q. The impact of antibiotic induction on virulence and antibiotic resistance in Klebsiella pneumoniae: a comparative study of CSKP and CRKP strains. Front Microbiol 2024; 15:1498779. [PMID: 39498139 PMCID: PMC11532078 DOI: 10.3389/fmicb.2024.1498779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 10/03/2024] [Indexed: 11/07/2024] Open
Abstract
Background Klebsiella pneumoniae is an opportunistic pathogen causing nosocomial infections, classified into carbapenem-sensitive and carbapenem-resistant strains. Understanding the virulence factors and antibiotic resistance of these strains is essential for effective clinical management. Objective This study compared the virulence genes and antibiotic resistance profiles of 50 CSKP and 50 CRKP strains, examining their expression under antibiotic pressure and the mechanisms contributing to their pathogenicity. Methods Virulence genes (rmpA, rmpA2, iucA, iutA, Peg-344, ybts, iroB) were detected in both strains using polymerase chain reaction (PCR). Antibiotic susceptibility testing established minimum inhibitory concentrations (MICs) for key antibiotics. Gene expression analysis was performed with quantitative reverse transcription PCR (qRT-PCR) after 10 days of antibiotic exposure. Results CSKP strains exhibited significantly higher positivity rates for virulence genes compared to CRKP strains. CRKP strains predominantly expressed resistance genes KPC, SHV, and CTX-M3, whereas no resistance genes were found in CSKP. Antibiotic susceptibility tests showed increased MICs, particularly for ciprofloxacin and imipenem, following antibiotic induction. CSKP demonstrated elevated expression of rmpA and rmpA2, while CRKP showed increased expression of SHV, and KPC after antibiotic exposure. Conclusion This study highlights the intricate relationship between virulence and resistance in Klebsiella pneumoniae. CSKP strains show strong virulence factor expression, while CRKP strains adapt to antibiotic pressure through altered gene expression patterns. These findings underscore the urgent need for continuous surveillance and innovative therapeutic strategies to combat multidrug-resistant Klebsiella pneumoniae infections.
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Affiliation(s)
- Ke-Da Chen
- Department of Blood Transfusion, The Affiliated LiHuiLi Hospital of Ningbo University, Ningbo, China
| | - Wei Chen
- Department of Blood Transfusion, The Affiliated LiHuiLi Hospital of Ningbo University, Ningbo, China
| | - Qian Zhang
- Department of Clinical Laboratory, The Affiliated LiHuiLi Hospital of Ningbo University, Ningbo, China
| | - Qingcao Li
- Department of Clinical Laboratory, The Affiliated LiHuiLi Hospital of Ningbo University, Ningbo, China
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Güneş S, Acer Ö, Bahçe YG. Carbapenem-resistant Klebsiella pneumoniae strains isolated from clinical specimens in Siirt, Türkiye; molecular characterization and antimicrobial resistance genes detection. Diagn Microbiol Infect Dis 2024; 110:116414. [PMID: 39032321 DOI: 10.1016/j.diagmicrobio.2024.116414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024]
Abstract
This study aimed to molecularly identify carbapenem-resistant Klebsiella pneumoniae (CRKP) strains isolated from clinical samples and to determine antibiotic resistance genes. Only carbapenem-resistant strains were included in our study. Of the 35 CRKP strains, 18 (51.4%) were extensive drug, 11 (31.4%) were multi-drug, and 6 (17.1%) were pan-drug resistances. PCR amplification revealed that 25% of the strains carried the OXA-51, 20% the OXA-48, and %5 the OXA23 genes. Multilocus sequence typing (MLST) analysis based on seven house-keeping genes revealed sequence type 39. The capsule and O-antigen types were determined as KL103 and O2a, respectively. WGS analysis revealed the existence of β-lactamase, aminoglycoside, sulfonamide, Phenicol, and Fosfomycin-resistant genes. While the K. pneumoniae OmpK37 gene was detected in all 3 strains, the OmpK36 gene was detected only in the CRSU20 strain. This study is important as it is the first study to perform molecular analysis of CRKP strains from Siirt, Türkiye.
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Affiliation(s)
- Sevgi Güneş
- Siirt University, Medical Faculty, Department of Biophysics, 56100 Siirt, Türkiye
| | - Ömer Acer
- Siirt University, Medical Faculty, Department of Medical Microbiology, 56100 Siirt, Türkiye.
| | - Yasemin Genç Bahçe
- Siirt Training and Research Hospital, Microbiology Laboratory, 56100 Siirt, Türkiye
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Gołębiewska JE, Krawczyk B, Wysocka M, Dudziak A, Dębska-Ślizień A. Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020198. [PMID: 36837399 PMCID: PMC9958684 DOI: 10.3390/medicina59020198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Urinary tract infections (UTIs) are the most prevalent complications in kidney transplant (KTx) recipients. The most frequent finding in this group of patients is asymptomatic bacteriuria (ASB). Here, we provide an overview of the available evidence regarding ASB in KTx recipients, including its etiopathology, clinical impact and management. There is a growing body of evidence from clinical trials that screening for and treating ASB is not beneficial in most KTx recipients. However, there are insufficient data to recommend or discourage the use of a "screen-and-treat strategy" for ASB during the first 1-2 months post-transplant or in the case of an indwelling urinary catheter. Despite its frequency, ASB after KTx is still an understudied phenomenon.
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Affiliation(s)
- Justyna E. Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
- Correspondence:
| | - Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, 80-233 Gdańsk, Poland
| | - Magdalena Wysocka
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, CRUK Manchester Institute, University of Manchester, Manchester M13 9PL, UK
| | - Aleksandra Dudziak
- Microbiology Laboratory, University Clinical Center, 80-952 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
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Sundaresan AK, Vincent K, Mohan GBM, Ramakrishnan J. Association of Sequence types, Antimicrobial Resistance and Virulence Genes in Indian isolates of Klebsiella pneumoniae: A Comparative Genomics Study. J Glob Antimicrob Resist 2022; 30:431-441. [DOI: 10.1016/j.jgar.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/06/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022] Open
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Krawczyk B, Wysocka M, Michalik M, Gołębiewska J. Urinary Tract Infections Caused by K. pneumoniae in Kidney Transplant Recipients – Epidemiology, Virulence and Antibiotic Resistance. Front Cell Infect Microbiol 2022; 12:861374. [PMID: 35531341 PMCID: PMC9068989 DOI: 10.3389/fcimb.2022.861374] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/23/2022] [Indexed: 12/11/2022] Open
Abstract
Urinary tract infections are the most common complication in kidney transplant recipients, possibly resulting in the deterioration of a long-term kidney allograft function and an increased risk of recipient’s death. K. pneumoniae has emerged as one of the most prevalent etiologic agents in the context of recurrent urinary tract infections, especially with multidrug resistant strains. This paper discusses the epidemiology and risk factors associated with urinary tract infections in kidney transplant recipients, multi-drug resistance of K. pneumoniae (ESBL, KPC, NDM), treatment and pathogenesis of K. pneumoniae infections, and possible causes of recurrent UTIs. It also addresses the issue of colonization/becoming a carrier of K. pneumoniae in the gastrointestinal tract and asymptomatic bacteriuria in relation to a symptomatic UTI development and epidemiology.
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Affiliation(s)
- Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
- *Correspondence: Beata Krawczyk,
| | - Magdalena Wysocka
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
| | | | - Justyna Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Ghenea AE, Zlatian OM, Cristea OM, Ungureanu A, Mititelu RR, Balasoiu AT, Vasile CM, Salan AI, Iliuta D, Popescu M, Udriștoiu AL, Balasoiu M. TEM,CTX-M,SHV Genes in ESBL-Producing Escherichia coli and Klebsiella pneumoniae Isolated from Clinical Samples in a County Clinical Emergency Hospital Romania-Predominance of CTX-M-15. Antibiotics (Basel) 2022; 11:antibiotics11040503. [PMID: 35453254 PMCID: PMC9028254 DOI: 10.3390/antibiotics11040503] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Background: CTX-M betalactamases have shown a rapid spread in the recent years among Enterobacteriaceae and have become the most prevalent Extended Spectrum Beta-Lactamases (ESBLs) in many parts of the world. The introduction and dissemination of antibiotic-resistant genes limits options for treatment, increases mortality and morbidity in patients, and leads to longer hospitalization and expensive costs. We aimed to identify the beta-lactamases circulating encoded by the genes blaCTX-M-15, blaSHV-1 and blaTEM-1 in Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) strains. Furthermore, we established the associated resistance phenotypes among patients hospitalized in the Intensive Care Unit (ICU) from County Clinical Emergency Hospital of Craiova, Romania. Methods: A total of 46 non-duplicated bacterial strains (14 strains of E. coli and 32 strains of K. pneumoniae), which were resistant to ceftazidime (CAZ) and cefotaxime (CTX) by Kirby–Bauer disk diffusion method, were identified using the automated VITEK2 system. Detection of ESBL-encoding genes and other resistance genes was carried out by PCR. Results. E. coli strains were resistant to 3rd generation cephalosporins and moderately resistant to quinolones, whereas K. pneumoniae strains were resistant to penicillins, cephalosporins, and sulfamides, and moderately resistant to quinolones and carbapenems. Most E. coli strains harbored blaCTX-M-15 gene (13/14 strains), a single strain had the blaSHV-1 gene, but 11 strains harbored blaTEM-1 gene. The mcr-1 gene was not detected. We detected tet(A) gene in six strains and tet(B) in one strain. In K. pneumoniae strains we detected blaCTX-M-15 in 23 strains, blaSHV-1 in all strains and blaTEM-1 in 14 strains. The colistin resistance gene mcr-1 was not detected. The tetracycline gene tet(A) was detected in 11 strains, but the gene tet(B) was not detected in any strains. Conclusions. The development in antibiotic resistance highlights the importance of establishing policies to reduce antibiotic use and improving the national resistance surveillance system in order to create local antibiotic therapy guidelines.
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Affiliation(s)
- Alice Elena Ghenea
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
| | - Ovidiu Mircea Zlatian
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
| | - Oana Mariana Cristea
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
- Correspondence: (O.M.C.); (C.M.V.)
| | - Anca Ungureanu
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
| | - Radu Razvan Mititelu
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
| | - Andrei Theodor Balasoiu
- Department of Ophthalmology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Corina Maria Vasile
- Department of Paediatrics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (O.M.C.); (C.M.V.)
| | - Alex-Ioan Salan
- Department of Oral and Maxillofacial Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Daniel Iliuta
- Department of Psychiatry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Anca-Loredana Udriștoiu
- Faculty of Automation, Computers and Electronics, University of Craiova, 200776 Craiova, Romania;
| | - Maria Balasoiu
- Department of Bacteriology-Virology-Parasitology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.E.G.); (O.M.Z.); (A.U.); (R.R.M.); (M.B.)
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