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1.
Nat Commun ; 12(1): 2241, 2021 04 14.
Artigo em Inglês | MEDLINE | ID: mdl-33854066

RESUMO

Antibiotic-induced modulation of the intestinal microbiota can lead to Clostridioides difficile infection (CDI), which is associated with considerable morbidity, mortality, and healthcare-costs globally. Therefore, identification of markers predictive of CDI could substantially contribute to guiding therapy and decreasing the infection burden. Here, we analyze the intestinal microbiota of hospitalized patients at increased CDI risk in a prospective, 90-day cohort-study before and after antibiotic treatment and at diarrhea onset. We show that patients developing CDI already exhibit significantly lower diversity before antibiotic treatment and a distinct microbiota enriched in Enterococcus and depleted of Ruminococcus, Blautia, Prevotella and Bifidobacterium compared to non-CDI patients. We find that antibiotic treatment-induced dysbiosis is class-specific with beta-lactams further increasing enterococcal abundance. Our findings, validated in an independent prospective patient cohort developing CDI, can be exploited to enrich for high-risk patients in prospective clinical trials, and to develop predictive microbiota-based diagnostics for management of patients at risk for CDI.


Assuntos
/fisiologia , Infecções por Clostridium/microbiologia , Microbioma Gastrointestinal , Idoso , Antibacterianos/uso terapêutico , Bactérias/classificação , Bactérias/genética , Bactérias/isolamento & purificação , Biomarcadores/análise , /genética , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
2.
Future Microbiol ; 16: 439-443, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33847139

RESUMO

The COVID-19 pandemic has changed the way we practice medicine and lead our lives. In addition to pulmonary symptoms; COVID-19 as a syndrome has multisystemic involvement including frequent gastrointestinal symptoms such as diarrhea. Due to microbiome alterations with COVID-19 and frequent antibiotic exposure, COVID-19 can be complicated by Clostridioides difficile infection. Co-infection with these two can be associated with a high risk of complications. Infection control measures in hospitals is enhanced due to the COVID-19 pandemic which in turn appears to reduce the incidence of hospital-acquired infections such as C. difficile infection. Another implication of COVID-19 and its potential transmissibility by stool is microbiome-based therapies. Potential stool donors should be screened COVID-19 symptoms and be tested for COVID-19.


Assuntos
Infecções por Clostridium , Coinfecção , Infecção Hospitalar/prevenção & controle , Fezes , Pandemias/prevenção & controle , /epidemiologia , /isolamento & purificação , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/terapia , Coinfecção/diagnóstico , Coinfecção/epidemiologia , Transplante de Microbiota Fecal , Fezes/microbiologia , Fezes/virologia , Humanos , Controle de Infecções , /isolamento & purificação
4.
Intern Med J ; 51(1): 106-110, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33572016

RESUMO

Faecal microbiota transplantation (FMT) is reportedly effective and safe for the management of recurrent or refractory Clostridioides difficile infection (CDI), yet real-world data of outcomes of FMT in Australia are limited. In this series, FMT safely resulted in resolution of CDI in 19 patients with reduced healthcare utilisation after 25 FMT, but one patient was diagnosed with an anti-nuclear antibody-positive constitutional illness and Hashimoto thyroiditis following FMT. Further prospective evaluation of the utility of FMT earlier in CDI treatment algorithms to minimise cost and morbidity, and recipient follow up for immune-mediated conditions, is required.


Assuntos
Infecções por Clostridium , Austrália , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/terapia , Transplante de Microbiota Fecal , Humanos , Recidiva , Resultado do Tratamento
6.
Arch Microbiol ; 203(4): 1683-1690, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33459815

RESUMO

Clostridioides difficile infection is a public health problem because of it is easily spread; with harmful consequences, it is essential to reduce hospital costs and prevent its dissemination by having a precise diagnosis. The gold standard for its diagnosis is polymerase chain reaction (PCR); however, the technique is not available for all laboratories due to the high cost. New approaches using non-molecular tests to detect C. difficile and toxin A/B production has been proposed to improve cost benefits. The objective of this study is to compare molecular methods (PCR) and rapid methods (immunochromatographic test and enzymatic immunoassay). A series of tests comprising these diagnostic techniques was performed with 50 patients with a clinical diagnosis for Clostridioides difficile on GeneXpert® devices test; a calculation of the sensitivity was executed, followed by a comparison of the efficiency of all techniques. Greater sensitivity was observed in the PCR-based methods (BD MAX™ and BioFire FilmArray®) and the GDH-based assays (RIDASCREEN® and Alere Techlab®). The proposed algorithm represents minor monetary disadvantages but a significant temporal optimization of 10%. Future studies concerning both positive and negative results could be advantageous because of the possibility of calculating more method concordance indexes, such as the specificity and Kappa index, in addition to being able to indicate a monetary profit if the proposed algorithm was applied due to the nonproceeding PCR cases.


Assuntos
Proteínas de Bactérias/análise , Toxinas Bacterianas/análise , Infecções por Clostridium/diagnóstico , Enterotoxinas/análise , Imunoensaio/métodos , Técnicas Imunoenzimáticas/métodos , Reação em Cadeia da Polimerase/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Proteínas de Bactérias/genética , /isolamento & purificação , Fezes/microbiologia , Feminino , Glutamato Desidrogenase/análise , Humanos , Laboratórios , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Adulto Jovem
7.
BMJ Case Rep ; 14(1)2021 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-33462050

RESUMO

Dasatinib, an oral tyrosine kinase inhibitor, is approved for therapy of chronic myeloid leukaemia (CML). Common adverse effects of this therapy include myelosuppression, fluid retention and diarrhoea. However, Clostridioides difficile infections (CDIs) in the context of dasatinib therapy, without a history of antecedent antibiotic use, has not been reported previously. We present here a case of a 36-year-old man diagnosed with accelerated phase of CML, who was started on treatment with dasatinib. Two months into therapy, he experienced profuse diarrhoea and abdominal pain. Colonoscopy revealed multiple confluent colonic mucosal ulcerations. Immunoassay study of stool revealed positive C. difficile toxin. The patient was started on oral metronidazole, with discontinuation of all other drugs, including dasatinib. He made a complete uneventful recovery following 2 weeks of antibiotic therapy. Chemotherapeutic agents, such as dasatinib, should be considered as possible etiological agents in the pathogenesis of CDI, even in absence of antibiotic use.


Assuntos
Antineoplásicos/efeitos adversos , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/etiologia , Dasatinibe/efeitos adversos , Diarreia/etiologia , Adulto , Infecções por Clostridium/terapia , Diarreia/diagnóstico , Diarreia/terapia , Humanos , Leucemia Mielogênica Crônica BCR-ABL Positiva/tratamento farmacológico , Masculino
8.
Zhonghua Liu Xing Bing Xue Za Zhi ; 42(1): 64-67, 2021 Jan 10.
Artigo em Chinês | MEDLINE | ID: mdl-33503698

RESUMO

Clostridioides difficile is a key pathogen of antibiotic related diarrhea and hospital associated infection, causing several outbreaks in Europe and North Americans and resulting in severe disease burden. However, the standardized diagnostic principle and detection specifications in C. difficile infection (CDI) survey are limited in China, and the infection rate and disease burden of CDI in China are unclear. Therefore, National Institute for Communicable Disease Control and Prevention,National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, together with another 11 institutions, draft the group standard entitled "Diagnosis of Clostridium difficile infection (T/CPMA 008-2020)" of Chinese Preventive Medicine Association. Based on the principle of "legality, scientificity, advancement, and feasibility", this standard clarifies risk factors, diagnosis principles, diagnoses and differential diagnoses in order to improve the accuracy of CDI diagnosis in clinical practice, guide the surveillance for CDI, and understand the infection rate and disease burden of CDI in China.


Assuntos
Infecções por Clostridium , China/epidemiologia , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/prevenção & controle , Humanos , Padrões de Referência
9.
Am J Case Rep ; 22: e928014, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33479190

RESUMO

BACKGROUND Lumbar discitis caused by Clostridium perfringens is extremely rare. There have only been 7 published cases of confirmed discitis caused by Clostridium perfringens. We write this report to underscore this unusual relationship by discussing an additional case and providing a review of the previously published cases so clinicians can adequately evaluate and treat patients presenting with discitis. CASE REPORT A 64-year-old morbidly obese man presented with an acute onset of worsening back pain and generalized weakness after incurring physical trauma related to falling. Additionally, he also developed fever and chills before the presentation. Based on the clinical presentation and elevated serum levels of inflammatory markers, magnetic resonance imaging was ordered, which showed L5-S1 discitis with extension of infection into the epidural space. Fluoroscopy-guided aspiration of the L5-S1 epidural space facilitated the detection of Clostridium perfringens as the involved pathogen. Based on the antibiotic susceptibility report, the patient was treated with intravenous ampicillin for 8 weeks, after which his symptoms resolved. CONCLUSIONS Diagnosis of discitis can be very challenging due to its ambiguous clinical presentation, especially in the elderly population due to the presence of underlying degenerative changes. Even though Clostridium perfringens remains a rare cause of lumbar discitis, it should be considered as a pathogen capable of causing infection of the vertebrae and intervertebral discs, thus allowing clinicians to make necessary diagnostic evaluations to provide appropriate targeted treatment to patients presenting with discitis.


Assuntos
Infecções por Clostridium/complicações , Clostridium perfringens/isolamento & purificação , Discite/complicações , Dor Lombar/etiologia , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/microbiologia , Discite/diagnóstico , Discite/microbiologia , Humanos , Dor Lombar/diagnóstico , Vértebras Lombares , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade
10.
J Med Case Rep ; 15(1): 2, 2021 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-33402156

RESUMO

BACKGROUND: Clostridium difficile (C. difficile) is a common cause of infectious colitis in individuals with prior antibiotic or hospital exposure. Extraintestinal manifestations of C. difficile infections, however, are rare. Here we present a case of C. difficile appendicitis in an immunocompromised patient. CASE PRESENTATION: A 53-year-old Caucasian male presented to the emergency room for two days of lower abdominal pain associated with nausea and subjective fevers. He otherwise denied having diarrhea or hematochezia. He did not have any recent hospitalizations, nursing home stays, or antibiotic exposure. His past medical history was notable for stage III tonsillar squamous cell carcinoma for which he was status post tonsillectomy, radiation therapy, and chemotherapy (cisplatin 4 days prior to presentation). He was afebrile with tenderness to palpation in the bilateral lower quadrants, right greater than left. His white blood cell (WBC) count was 15.6 × 103 cells/µL. Computed tomography (CT) of the abdomen and pelvis showed marked edema and inflammation of the cecum and ascending colon as well as an enlarged appendix with surrounding inflammatory changes with a small amount of free fluid in the right paracolic gutter. He was treated non-surgically with antibiotics. He did not clinically improve and on hospital day 3, he developed diarrhea for which C. difficile stool polymerase chain reaction was sent. Repeat CT of the abdomen and pelvis was performed which showed progression to pan-colitis and persistent appendicitis. C. difficile testing later resulted positive, for which oral vancomycin was started. The patient markedly improved with medical management alone and was subsequently discharged on oral vancomycin. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for C. difficile in a patient presenting with both appendicitis and colitis, with prompt diagnosis and treatment being essential.


Assuntos
Apendicite , Infecções por Clostridium , Apendicite/diagnóstico , Infecções por Clostridium/complicações , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/tratamento farmacológico , Diarreia/etiologia , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade
14.
BMC Infect Dis ; 20(1): 785, 2020 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-33087051

RESUMO

BACKGROUND: Literature is scarce regarding oral step down to beta-lactams in bacteremic urinary tract infections. Oral fluoroquinolones are an accepted and common step down for bacteremic urinary tract infections; however, their use is associated with mounting safety concerns. We compared clinical cure in patients with E. coli bacteremic urinary tract infections who were stepped down to oral beta-lactams compared to oral fluoroquinolones. METHODS: This multicentre retrospective cohort study included patients with first positive concurrent urine and blood cultures from January 2016 to December 2016. Patients were included if they received empiric intravenous beta-lactam therapy with step down to either oral beta-lactam or fluoroquinolone for treatment completion. The primary outcome was clinical cure. Secondary outcomes were length of hospitalization, all-cause mortality and C. difficile infection. Multivariate analysis and propensity score were used to control for confounding. RESULTS: A total of 207 patients were identified with bacteremic E.coli urinary tract infections. Clinical cure was achieved in 72/77 (94%) in the oral beta-lactam group versus 127/130 (98%) in the oral fluoroquinolone group (absolute difference - 4.2, 95% confidence interval [CI] -10.3 to 1.9%, p = 0.13). The adjusted odds ratio (OR) for clinical cure with oral beta-lactams was 0.31 (95% CI 0.05-1.90, p = 0.21); propensity score adjusted analysis showed a similar result. There was no statistically significant difference in secondary outcomes. CONCLUSIONS: Oral beta-lactams appear to be a safe and effective step down option in bacteremic E. coli urinary tract infections compared to oral fluoroquinolones.


Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Infecções por Escherichia coli/tratamento farmacológico , Escherichia coli/isolamento & purificação , Fluoroquinolonas/uso terapêutico , Infecções Urinárias/tratamento farmacológico , beta-Lactamas/uso terapêutico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Bacteriemia/microbiologia , Hemocultura , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/microbiologia , Infecções por Escherichia coli/microbiologia , Feminino , Fluoroquinolonas/administração & dosagem , Fluoroquinolonas/efeitos adversos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Infecções Urinárias/microbiologia , beta-Lactamas/administração & dosagem , beta-Lactamas/efeitos adversos
15.
S Afr Med J ; 110(2): 135-139, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657685

RESUMO

BACKGROUND: Clostridiodes difficile is a common cause of healthcare-associated diarrhoea. Laboratory testing for C. difficile infection (CDI) remains an area of confusion, as there is not a single accepted reference standard or a single best test. OBJECTIVES: To analyse the impact of different diagnostic methods on reported CDI rates. In addition, CDI incidence rates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa, were determined. METHODS: Results of stool samples submitted for C. difficile testing at CMJAH from 1 January 2014 to 31 August 2017 were reviewed. From January 2014 to July 2016, samples were tested by polymerase chain reaction (PCR) or toxin immunoassay, and from August 2016 to August 2017, algorithm-based testing (glutamate dehydrogenase and toxin immunoassay followed by PCR) was performed. RESULTS: A total of 4 829 samples were submitted. For the first period, toxin immunoassay and PCR showed a positivity rate of 11.4% and 21.1%, respectively, with an overall positivity rate of 18.7% (95% confidence interval (CI) 15.6 - 21.9). For the second period, the positivity rate was 15.9% (95% CI 11.3 - 17.7). This rate included samples that were GDH-positive and either showed toxin production or had a positive Xpert result. The CDI incidence for the two periods was different, with an incidence rate of 8.8 and 6.1 per 10 000 patient-days for the first and second periods, respectively. CONCLUSIONS: The choice of laboratory testing method has a major impact on the diagnosis of CDI, and therefore on reported rates of CDI. Standardisation of laboratory testing and incidence rate reporting is required in order to obtain robust and reliable data.


Assuntos
/isolamento & purificação , Infecções por Clostridium/diagnóstico , Diarreia/diagnóstico , Reação em Cadeia da Polimerase/métodos , Algoritmos , Infecções por Clostridium/epidemiologia , Diarreia/microbiologia , Glutamato Desidrogenase/análise , Humanos , Imunoensaio/métodos , Incidência , Estudos Retrospectivos , África do Sul
17.
Med. clín (Ed. impr.) ; 155(1): 30-35, jul. 2020. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-195692

RESUMO

Clostridioides difficile es el principal responsable de la diarrea asociada con la atención sanitaria en adultos. La incidencia de la infección por C.difficile (ICD) ha aumentado en los últimos años. El riesgo de recidivas de la ICD es del 15-25% en un primer episodio, y este riesgo se incrementa en los posteriores episodios. Las técnicas de referencia para el diagnóstico microbiológico de la ICD son el cultivo toxigénico y el ensayo de citotoxicidad. Son técnicas laboriosas y lentas, por lo que han sido sustituidas en la práctica clínica por la aplicación de un algoritmo de varios pasos que incluye la detección de glutamato deshidrogenasa (GDH), toxinas y técnicas moleculares. El tratamiento de elección de la ICD es la vancomicina. En los últimos años han aparecido nuevos fármacos y nuevas estrategias especialmente útiles en el tratamiento de las recidivas de la ICD


Clostridioides difficile is the main cause of healthcare-associated diarrhoea in adults. The incidence of C.difficile infection (CDI) has increased in recent years. The risk of recurrence of CDI is 15%-25% in a first episode and this risk is increased in subsequent episodes. Toxigenic culture and cytotoxicity tests are the reference techniques for the microbiological diagnosis of CDI. These are laborious and slow techniques and therefore they have been replaced in clinical practice by the application of a multi-step algorithm that includes the detection of glutamate dehydrogenase (GDH), toxins and molecular techniques. The treatment of choice for CDI is Vancomycin. In recent years, new drugs and new treatment strategies have appeared that are especially useful in the treatment of relapses of CDI


Assuntos
Humanos , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/tratamento farmacológico , Infecções por Clostridium/microbiologia , Clostridium difficile/efeitos dos fármacos , Clostridium difficile/isolamento & purificação , Vancomicina/administração & dosagem , Microbioma Gastrointestinal/efeitos dos fármacos
18.
PLoS One ; 15(6): e0234119, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32492051

RESUMO

Recently, a new rapid assay for the detection of tcdB gene of Clostridioides difficile was developed using the GENECUBE. The assay can directly detect the tcdB gene from stool samples without a purification in approximately 35 minutes with a few minutes of preparation process. We performed a prospective comparative study of the performance of the assay at eight institutions in Japan. Fresh residual stool samples (Bristol stool scale ≥5) were used and comparisons were performed with the BD MAX Cdiff assay and toxigenic cultures. For the evaluation of 383 stool samples compared with the BD MAX Cdiff assay, the sensitivity, and specificity of the two assays was 99.0% (379/383), 98.1% (52/53), 99.1% (327/330), respectively. In the comparison with toxigenic culture, the total, sensitivity, and specificity were 96.6% (370/383), 85.0% (51/60), and 98.8% (319/323), respectively. The current investigation indicated the GENECUBE Clostridioides difficile assay has equivalent performance with the BD MAX Cdiff assay for the detection of tcdB gene of C. difficile.


Assuntos
Proteínas de Bactérias/genética , Toxinas Bacterianas/genética , Fezes/microbiologia , /isolamento & purificação , Infecções por Clostridium/diagnóstico , DNA Bacteriano/genética , DNA Bacteriano/metabolismo , Enterotoxinas/genética , Humanos , Reação em Cadeia da Polimerase/métodos , Kit de Reagentes para Diagnóstico , Proteínas Repressoras/genética , Sensibilidade e Especificidade
19.
Am J Gastroenterol ; 115(8): 1153-1155, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32496340

Assuntos
Infecções por Coronavirus/fisiopatologia , Doenças do Sistema Digestório/fisiopatologia , Pneumonia Viral/fisiopatologia , Dor Abdominal/etiologia , Dor Abdominal/metabolismo , Dor Abdominal/fisiopatologia , Dor Abdominal/terapia , Assistência Ambulatorial , Anorexia/etiologia , Anorexia/metabolismo , Anorexia/fisiopatologia , Anorexia/terapia , Antibacterianos/efeitos adversos , Antipiréticos/efeitos adversos , Antivirais/efeitos adversos , Betacoronavirus , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Doença Hepática Induzida por Substâncias e Drogas/metabolismo , Doença Hepática Induzida por Substâncias e Drogas/fisiopatologia , Doença Hepática Induzida por Substâncias e Drogas/terapia , China , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/tratamento farmacológico , Infecções por Coronavirus/complicações , Infecções por Coronavirus/metabolismo , Infecções por Coronavirus/terapia , Diarreia/etiologia , Diarreia/metabolismo , Diarreia/fisiopatologia , Diarreia/terapia , Doenças do Sistema Digestório/etiologia , Doenças do Sistema Digestório/metabolismo , Doenças do Sistema Digestório/terapia , Endoscopia do Sistema Digestório , Gastroenterologia , Humanos , Hepatopatias/etiologia , Hepatopatias/metabolismo , Hepatopatias/fisiopatologia , Hepatopatias/terapia , Náusea/etiologia , Náusea/metabolismo , Náusea/fisiopatologia , Náusea/terapia , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/metabolismo , Pneumonia Viral/terapia , Probióticos/uso terapêutico , Sociedades Médicas , Vômito/etiologia
20.
Med Clin North Am ; 104(4): 663-679, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32505259

RESUMO

Hospital-acquired infections increase cost, morbidity, and mortality for patients across the United States and the world. Principal among these infections are central line-associated bloodstream infection, catheter-associated urinary tract infection, Clostridioides difficile, and methicillin-resistant Staphylococcus aureus colonization and infections. This article provides succinct summaries of the background, epidemiology, diagnosis, and treatment of these conditions. In addition, novel prevention strategies, including those related to recent national interventions, are reviewed.


Assuntos
Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/epidemiologia , Infecções por Clostridium/epidemiologia , Infecções Estafilocócicas/epidemiologia , Infecções Urinárias/epidemiologia , Bacteriemia/tratamento farmacológico , Bacteriemia/microbiologia , Bacteriemia/terapia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/prevenção & controle , Infecções Relacionadas a Cateter/terapia , Cateteres de Demora/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/prevenção & controle , Infecções por Clostridium/terapia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Humanos , Incidência , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/prevenção & controle , Infecções Estafilocócicas/terapia , Estados Unidos/epidemiologia , Infecções Urinárias/diagnóstico , Infecções Urinárias/prevenção & controle , Infecções Urinárias/terapia
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