Volume 27, Issue 4, 2019
Review
Emerging antibiotic resistance: carbapenemase-producing enterobacteria. Bad new bugs, still no new drugs.
Spera Anna Maria,
Esposito Silvano,
Pagliano Pasquale
Antimicrobial resistance (AMR) is a global health security threat requiring actions across government sectors and society. Many factors are involved in this phenomenon, being overuse of antibiotics, incorrect antibiotic prophylaxis, and use of antibiotics for zootechnic reasons the main causes of the increasing rate of multi-drug resistant (MDR) bacteria.
The impact of resistance to antimicrobials is an important threat due also to the emergence of MDR Gram-negative bacteria resistant to carbapenems, and the lack of the research for new active molecules. The production of extended spectrum beta-lactamase enzymes has been the first threatening mechanism for Gram-negative resistance to antibiotics, which prompted the development of new classes of antibiotics such as carbapenems. Unfortunately, resistance to carbapenems developed because of multiple mechanisms including efflux pumps, porin mutations and enzyme production, being the latter particularly relevant in terms of diffusion due to the genes located within plasmids that drive their horizontal diffusion.
In this scenario, antimicrobial stewardship programs (ASP) are a mandatory resource in fighting the resistance spread. The reduction of total amount of antibiotics administration in the hospital setting and guiding prescribers in the correct administration of antibiotics for the smallest period possible, at the correct dosage, can be defined as the first goals of an ASP. Anyway, in an efficacious ASP, apart from antibiotic administration, efforts must been made in ensuring the lowest probability of spreading of MDR by efficacious measures of isolation of carriers, and by offering tools for a rapid diagnosis of viral infections avoiding the administration of unnecessary antibiotics. A continuous audit of the ASP programs and a correct assessment of the allergy to drugs such as penicillin have to complete the program. Currently, only a few options are available for patients with an infection sustained by Gram-negative MDR bacteria. All the options actually available are based on the administration of colystin, an old drug whose real efficacy is reduced due to its relevant toxicity, or on the administration of recently proposed drugs such as ceftolozane-tazobactam, ceftazidime-avibactam and meropenem-vaborbactam. All these new drugs do not have a novel mechanism of action and have limited spectrum in term of activity against MDR bacteria.
In conclusion, antimicrobial resistance is a global emergence and AMP is the most powerful tool actually available. Few limited options are available to treat infections due to Carbapenem Resistant Enterobacteria. Antimicrobial molecules with true novel mechanism of action are needed to win the fight against antimicrobial resistance.
Clinical pharmacology of the single tablet regimen bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF)
Di Perri Giovanni
The fourth HIV strand-transfer integrase inhibitor (INSTI) has been released into the market as part of a single-tablet-regimen (STR) consisting of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). The newest component is thus BIC, a booster-free INSTI with pharmacological characteristics similar to those of dolutegravir (DTG), including high intrinsic antiretroviral potency. The BIC-containing STR underwent clinical development in both treatment-naïve and virologically suppressed patients and was found non-inferior to DTG-based comparator arms. In the currently evolving therapeutic scenario, the BIC/FTC/TAF STR regimen represents the smartest response on the side of triple conventional regimens, while new 2-drug regimens have received regulatory approval and nowadays epitomize the search for simpler and lighter antiretroviral regimens. The overall characteristics of BIC/FTC/TAF, however, make this therapeutic option quite comparable in terms of simplicity to the newly approved dual regimens, and the main reasons (e.g., toxicity) accounting in the past for the search of regimens consisting of less than three drugs are no longer in place.
Original article
Bacterial resistance in cell phone cultures of medical students
Nieto-Carhuamaca Arnold,
Castañeda-Japan Jhonatan,
Dámaso-Mata Bernardo,
Panduro-Correa Vicky,
Arteaga-Livias Kovy
Cell phones are one of the most important and indispensable accessories for professional and social life. Cell phones used by healthcare workers are highly contaminated by microorganisms. The objective of the study was to ascertain the presence of bacterial resistance type Extended-Spectrum Beta-Lactamase [ESBL] and its related factors in cultures isolated from cell phones of medical students. A quantitative, observational, analytical and transversal study was carried out in students of the Faculty of Medicine of the Universidad Nacional Hermilio Valdizán in Huánuco, Peru. The relationship was sought between the frequency of attendance at hospital practices, cell phone disinfection and hand washing after contact with patients with the presence of ESBL-type bacterial resistance. Of the total sample, 95% of students presented positive culture to Gram-negative bacteria, 30% carried out the disinfection of their cell phone and only 5% of the students performed hand-washing in an appropriate manner. In the bivariate analysis, a statistical association was found between cell phone disinfection and the presence of ESBL-type bacterial resistance [p <0.05]. Cell phone disinfection is related to the reduction of ESBL-type resistance, highlighting the need for disinfection of cell phones after performing hospital practices.
Risk factors for acute kidney injury in critically ill patients with bacteraemia by carbapenem non-susceptible Gram negative bacteria
Papadimitriou-Olivgeris Matthaios,
Assimakopoulos Stelios F.,
Kolonitsiou Fevronia,
Solomou Anastasia,
Vamvakopoulou Sophia,
Spyropoulou Aikaterini,
Karamouzos Vasileios,
Anastassiou Evangelos D.,
Papachristou Evangelos,
Spiliopoulou Iris,
Christofidou Myrto,
Fligou Fotini,
Marangos Markos
The objectives of the present study were to identify risk factors for development of acute kidney injury (AKI) during the treatment of bacteraemia due to carbapenem non-susceptible Gram-negative bacteria (CnS-GNB) and its role on mortality. Data of all patients with bacteraemia by CnS-GNB in the intensive care unit of a tertiary hospital from 2012 to 2016 were included. AKI was defined by AKIN criteria. Secondary outcomes were AKI development in patients treated with colistin and predictors of 14-day mortality. Among 285 episodes of bacteraemia due to CnS-GNB, 84 (29.5%) developed AKI. Multivariate analysis revealed that obesity, septic shock, maximum noradrenaline dose and eGFR<60 mL/min/1.73m2 upon bacteraemia onset were independently associated with development of AKI. Out of 228 patients receiving colistin, 64 (28.1%) developed AKI. Multivariate analysis found the same factors as before in addition to voriconazole administration. Fourteen-day mortality was 34.2% and was independently associated with bacteraemia by Pseudomonas aeruginosa, AKI during bacteraemia treatment, maximum noradrenaline dose, SAPS II and SOFA scores upon bacteraemia onset, whereas appropriate combination therapy and catheter-related bacteraemia were independently associated with better survival. AKI was a frequent complication of bacteraemia by CnS-GNB and was associated with septic shock and baseline renal function impairment. Mortality was higher among patients that developed AKI due to bacteraemia. Colistin should be considered a safe therapeutic option for treating such infections.
Incidence of pertussis in the province of Pesaro-Urbino (Italy)
Brindicci Gaetano,
Loconsole Daniela,
Carboni Danilo,
Genga Roberto,
Moschini Eleonora,
Montorzi Giulia,
Viscogliosi Felicetta,
Pompili Marco,
Agostini Massimo,
Ripanti Gabriele
Pertussis vaccination coverage in the Marche region is one of the lowest in Italy, with the province of Pesaro-Urbino remaining stable below 95% coverage since at least 2013. In this paper, we retrospectively analyzed all whooping cough notification cards arriving at the prevention department of the Area Vasta 1 Health Office in the Marche region and relating to the Pesaro-Urbino province (Italy). Between 2012 and 2017, there were 28 reported cases of pertussis with a peak in 2016 (11 cases, of which seven were in Urbino). The 28 patients were mostly male (65%), and had a mean age of 9 years. Three of these were not Italian. Between 2012 and 2017, the district of Pesaro reported the highest number of cases (almost 46.5% of the total), followed by Urbino (28.5%) and Fano (25%). The average incidence in the province in the period in question, still under 2 cases/100,000 inhabitants, arrived in 2016 at 4 cases/100,000 inhabitants. In particular, in Urbino there was an unforeseen incidence >8 cases/100,000 inhabitants. There were no deaths, although two children (both under 12 months of age) were hospitalized. Our data confirm that in 2016 there was a pertussis epidemic in Urbino (Italy).
Clinical spectrum and outcome of hospitalized patients with invasive fungal infections: a prospective study from a medical ward/intensive care unit of a teaching hospital in North India
Sindhu Devada,
Jorwal Pankaj,
Gupta Nitin,
Xess Immaculata,
Singh Gagandeep,
Soneja Manish,
Nischal Neeraj,
Sethi Prayas,
Ray Animesh,
Biswas Ashutosh,
Wig Naveet
The aim of the study was to determine the clinical spectrum and outcome of invasive fungal infections (IFIs) in hospitalized patients. A prospective study was conducted in a teaching hospital in North India between December 2016 and December 2018. Patients diagnosed with IFIs were enrolled. Their clinical and laboratory parameters were recorded using a pre-defined clinical report form. They were followed up till discharge or death and a 60-day outcome was recorded. A total of 110 IFI cases were identified, which included invasive aspergillosis (39%), invasive candidiasis (16%), cryptococcosis (14%) and mucormycosis (12%). Pneumonia (63%) was the most common final diagnosis in these patients. Diabetes mellitus, chronic kidney disease and chronic obstructive pulmonary disease were the most common risk factor for all four diseases. Additionally, most patients with cryptococcosis had human immunodeficiency virus infection. Mortality was observed in 73% of the patients. Overall, IFIs are an important cause of morbidity and mortality in critically ill patients admitted to medical wards and ICUs.
An outbreak of candidemia due to Candida parapsilosis in an adult intensive care unit
Hacıseyitoğlu Demet,
Çağ Yasemin
Candida spp. is one of the most common causes of nosocomial bloodstream infections, and Candida parapsilosis is an emerging pathogen that is associated with nosocomial outbreaks. We aimed to characterize an outbreak of candidemia due to C. parapsilosis in our hospital’s adult intensive care unit to investigate the clonal relationship of isolates. This is a retrospective study designed to investigate an outbreak of C. parapsilosis bloodstream infections (BSIs) which developed during an 11-week period from July to October 2012. Thirteen outbreak isolates and five isolates from the previous five sporadic cases were included in the study. Identification and antifungal susceptibilities of the isolates were determined by using MALDI-TOF MS (VITEK MS, bioMérieux, France) and by Etest (bioMérieux, France) on RPMI 1640-2% glucose agar (bioMérieux, France) at the Clinical Microbiology Laboratory. Clonal relationships were investigated by repetitive sequence-based PCR (rep-PCR) (DiversiLab, bioMérieux, Marcy l’Etoile, France).
The mean age of the cases, seven of which were female, was 61 years. The mean Candida score was 3, the mean length of stay in the intensive care unit (ICU) before infection developed was 33 days. A microbiological cure was obtained in nine (69.2%) patients with appropriate antifungals and catheter removal. Six patients died in a mean of 24 days.
All of these isolates were obtained from blood culture, three being also obtained from CVC tips culture. Sixteen isolates were C. parapsilosis, and two isolates were C. orthopsilosis. All of the isolates were susceptible to amphotericin B, voriconazole, and caspofungin. Three isolates were resistant to fluconazole, and two isolates were dose-dependent susceptible to fluconazole. Out of the 13 outbreak isolates and five previous isolates, 11 and three, respectively, showed the same rep-PCR genotypic profile (genotype 1). Two isolates were the second same genotypic profile (genotype 2), and two isolates were the third same genotypic profile (genotype 3). The outbreak was under control in 11 weeks. The sporadic cases occurred in a subsequent three-month period. Our study shows that if C. parapsilosis isolates are present in a unit, it can become colonized in the unit and can spread clonally and rapidly, being able to cause a nosocomial outbreak. Moreover, even one isolate of C. parapsilosis in a unit can trigger an outbreak. Molecular typing methods are essential in order to illustrate the epidemiology of hospital outbreaks. Early detection of outbreaks is crucial for the implementation of infection control measures such as disinfection and isolation.
Single tablet regimen with abacavir/lamivudine/dolutegravir compared with two-drug regimen with lamivudine and dolutegravir as different strategies of simplification from a multicenter HIV cohort study
Baldin Gianmaria,
Ciccullo Arturo,
Rusconi Stefano,
Madeddu Giordano,
Sterrantino Gaetana,
Freedman Andrew,
Giacometti Andrea,
Celani Luigi,
Latini Alessandra,
Rossetti Barbara,
Cossu Maria Vittoria,
Giacomelli Andrea,
Lagi Filippo,
Capetti Amedeo,
Di Giambenedetto Simona
We investigated the effectiveness and safety of a dual therapy (DT) with lamivudine plus dolutegravir versus a single tablet regimen (STR) with abacavir/lamivudine/dolutegravir. We performed a retrospective analysis in a cohort of virologically suppressed HIV+ patients switching to lamivudine-dolutegravir or abacavir/lamivudine/dolutegravir. We evaluated the incidence of virological failure and treatment discontinuation, as well as their predictors. Non-parametric tests were applied to assess changes in immunological and metabolic parameters.
In all, 616 patients were analyzed: 380 began STR and 236 DT. In the STR group three patients experienced VF; in the DT group seven patients experienced VF. No differences in cause of treatment discontinuation were found. The estimated probability of continuing therapy at 48 weeks were 88.5 % in DT and 90.3% in STR, without a statistically significant difference (Log-rank 0.338). Regarding the metabolic profile, in the STR group there was a reduction in LDL cholesterol levels at week 48 (p=0.008), whereas in the lamivudine group there was a significant reduction in total cholesterol level at week 48 (p=0.044). Regarding the renal function, in both groups we registered a reduction in estimated glomerular filtration rate (eGFR), with a median reduction of 8.4 ml/min in the STR group (p<0.001) and 10.2 mL/min in DT (p<0.001). We found a difference in strategy option: in a context of side effect and comorbidities, dual therapy strategy was preferred. Conversely, simplification and compliance improvement more frequently translated into a DTG-STR strategy.
HIV rapid test in a community setting as a strategy to improve access to HIV testing: data from a multicentre experience in Italy
Falanga Carmine,
Marotta Claudia,
Negri Silvia,
Di Gennaro Francesco,
Bavaro Davide Fiore,
Poliseno Mariacristina,
Mazzucco Walter,
Monno Laura,
Saracino Annalisa,
Lo Caputo Sergio
4,000 new HIV diagnoses and approximately 800 AIDS cases are still reported annually in Italy. Improving public awareness and bringing out HIV-undiagnosed individuals are keystones to progress towards the control of the HIV epidemic. For this purpose, the Open HIV TEST project was organized and delivered by the Italian NGO Anlaids, together with local infectious diseases specialists, in order to provide free access to HIV testing outside the healthcare setting. Between October 2017 and February 2019 six Open HIV TEST initiatives were delivered in six Italian cities (3 northern cities, 1 central and 2 southern cities). In all, 581 people were tested: the overall prevalence of HIV test reactivity was 0.7%. Participants were also asked about previous screenings and about their satisfaction with the initiative: previous HIV screening due to pregnancy or surgical procedures was reported mainly by participants in northern centres (p<0.001); finally, the initiative was considered useful and noteworthy by 99% of participants. Prevalence of HIV test reactivity in our experience was in line with national data. Our experience suggests that active testing and counselling strategies in community settings should be recommended and institutionalized by local health authorities in line with the 90-90-90 global strategy.
Surgical treatment of liver echinococcosis and alveococcosis
Panteleev Vladimir,
Nartaylakov Mazhit,
Mustafin Airat,
Abdeyev Rustem,
Salimgareyev Ildar,
Samorodov Aleksandr,
Musharapov Denis
Parasitic liver zoonoses are endemic to some regions of Russia as well as to Mediterranean countries, Australia, New Zealand, South America, and the Indian subcontinent. However, the available data on the surgical treatment of patients with parasitic liver diseases are often contradictory, and such treatments remain a difficult task today. The effectiveness of surgical treatment was analyzed in 628 patients with echinococcosis and 58 patients with liver alveococcosis managed at the Republican Clinical Hospital during 1998-2018. The most commonly performed surgery for echinococcosis was closed echinococcectomy of different types, which was applied in 428 patients. Surgical outcomes were evaluated according to the type of surgery. Although there were no differences in outcomes in the immediate postoperative period, long-term postoperative outcomes differed with the type of surgery, compelling us to reconsider the surgical methods employed, with a preference for implementing cystectomy with omentoplasty of the residual cavity of the liver. In fact, the best outcomes in terms of recurrence and complications were obtained with minimal but adequate procedures, namely actual echinococcectomy without the resection of the residual cavity or liver. Thus procedures with low-traumatic access should be performed in cases with specific indications, such as the presence of easily accessible and well-visualized parasitic cysts.
Case report
Necrotizing fasciitis and sepsis caused by Aeromonas hydrophila
Tsujimoto Yasutaka,
Kanzawa Yohei,
Seto Hiroyuki,
Nakajima Takahiro,
Ishimaru Naoto,
Waki Takahiro,
Kinami Saori
Aeromonas hydrophila (A. hydrophila) occasionally causes necrotizing fasciitis (NF) and sepsis in immunocompromised hosts. NF is associated with high mortality. In cases of septic shock due to A. hydrophila, mortality is nearly 100%. Our 47-year-old male patient was diagnosed with NF and septic shock due to A. hydrophila. He had not been exposed to fresh or slightly salty water, which is where the bacterium is typically found, so its origin in this case is unclear. This is the first known case in which the patient was able to be completely cured without amputation. NF was suspected from his sepsis, medical history including alcoholic cirrhosis, and a severely poor general condition, but his skin lesions were mild. We promptly made an exploratory incision and debrided his legs. NF could then be diagnosed. At an early stage, A. hydrophila was recognized as a possible pathogen of NF because of the patient’s medical background and the Gram stain findings of intraoperative exudate. Minocycline in addition to carbapenem and vancomycin plus clindamycin were administered as empiric therapy. When A. hydrophila was detected in the blood culture, ciprofloxacin was administered as definitive therapy. Successful treatment of NF requires early diagnosis, prompt debridement from onset and adequate empirical antibiotic therapy.
Isoniazid-induced Takayasu arteritis remission
Agostinis Paolo,
Antonello Roberta Maria,
Orsaria Maria,
Luzzati Roberto,
Di Bella Stefano
A 75-year-old man was admitted because of fever, unproductive cough, neck pain and upper limb claudication. The patient was febrile and hypotensive, and a cardiac systolic ejection murmur was heard. Blood tests showed normochromic anemia, elevated erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and alpha-2 and beta-2 globulins. In order to investigate neck pain, an ultrasound examination of the carotid arteries was performed which showed a carotid intima-media thickness reaching the maximum value of 2.3 mm in both carotid arteries. Ultrasound examination of the temporal artery and its rami demonstrated wall thickening, both in the common superficial temporal artery and its frontal and parietal rami. A temporal artery biopsy was performed and was consistent with Takayasu arteritis. A positive interferon-γ release assay revealed latent tuberculosis infection and isoniazid 300 mg every 24 hours was commenced. Neither corticosteroids nor other drugs were prescribed at that time. Two weeks later, ultrasound examination showed a significant reduction in the thickening of all investigated arteries. To our knowledge, this is the first case of isoniazid-induced Takayasu arteritis remission. We believe that isoniazid deserves further investigation regarding its potential immunomodulatory properties.
Do we care if you have a cat? Bartonella infection related glomerulonephritis with no endocarditis
Singhania Girish,
Singhania Namrata
Bartonella infection has been associated with culture negative endocarditis and in rare cases immune complex medicated rapidly progressive glomerulonephritis (RPGN). Most of the previously reported cases of RPGN are associated with endocarditis. We report a case of RPGN with no endocarditis secondary to Bartonella infection. Good social history, high index of suspicion, diagnosis with polymerase chain reaction and treatment with antibiotics is the key for treatment.
Iatrogenic Cushing syndrome due to drug interaction between inhaled fluticasone and cobicistat
Monge Elisa,
Colombo Valeria,
Giacomelli Andrea
In this paper we report a case of iatrogenic Cushing syndrome due to a pharmacological interaction between fluticasone and cobicistat. Inhaled corticosteroids were previously thought to be safe, but increasing numbers of cases of iatrogenic Cushing syndrome are being reported, especially in patients taking cytochrome P450 inhibitors, including cobicistat. Although the drug interaction between cobicistat and fluticasone has been described elsewhere, to our knowledge we present one of the first descriptions of iatrogenic Cushing syndrome due to this pharmacological interaction.
Herpes zoster after vaccination with one dose varicella vaccine to a 4-year-old child.
Pelekouda Eleni,
Papagiannis Dimitrios,
Tsiaousi Ioanna,
Maltezou Helena C.
Clinical observations from the international literature report that herpes zoster occurs after varicella vaccination in immunocompetent children. We present the case of a four-year-old immunocompetent girl who developed herpes zoster after she had received one dose of varicella-zoster virus live attenuated vaccine at the age of 15 months. Continued surveillance for herpes zoster among vaccinated persons is important to evaluate the varicella vaccination program and to detect any changes in the epidemiology of herpes zoster. Vaccinated children appear to have a lower risk of herpes zoster than people who were infected naturally with varicella zoster virus (chickenpox).
Use of miltefosine in a patient with mucosal leishmaniasis and HIV-coinfection: a challenge in long-term management
Zanelli Giacomo,
Rossetti Barbara,
Gagliardini Roberta,
Paglicci Lorenzo,
Tordini Giacinta,
Miracco Clelia,
Aversa Sara,
Zammarchi Lorenzo,
Di Muccio Trentina,
Gramiccia Marina,
Montagnani Francesca
The management of mucosal leishmaniasis in immunocompromised patients is not standardized and limited data are available on the use of miltefosine for treatment and secondary prophylaxis. We describe a case of mucosal leishmaniasis in an HIV-coinfected patient treated with miltefosine due to a severe allergic reaction to liposomal amphotericin B.
Pelvic echinococcosis presenting as a mass in the gluteal region: a case report
Banerjee Sumit,
Gupta Akshat,
Choudhary Ramkaran,
Rathore Khushwant Singh,
Khera Sudeep
Hydatid disease of the skeletal system is a rare entity. We present one such case of pelvic echinococcosis in a 62-year-old male who presented with the chief complaints of pain and swelling in the left gluteal region for the past twelve years. The patient was planned for and underwent en-bloc excision of the lesion. Albendazole was used pre- and post-operatively to reduce parasitic load. At the last follow-up, the patient was disease-free and able to carry out his daily activities without much difficulty. We would conclude that, although uncommon, echinococcosis should always be ruled out, especially when dealing with other indolent pathologies of the hip joint.
The Infections in the History of Medicine
Thessaly and medicine from ancient Greek mythology to contemporary times: a perpetual relationship
Papagiannis Dimitrios,
Rachiotis Georgios
The aim of this narrative review is to provide an overview of the connection between Thessaly and the development of medicine from ancient Greek mythology to contemporary times. From Chiron to Asclepius, from Asclepius to Hippocrates, and from Hippocrates to the true Hippocratic epidemiologist Dimitrios Trichopoulos, a plethora of myths and facts indicate the strong and perpetual alignment between Thessaly and the science of medicine.
The health of Italian troops and prisoners during World War I
Sabbatani Sergio,
Fiorino Sirio,
Manfredi Roberto
During the Great War, which involved Italy from May 1915 until November 1918, the Italian Army paid an extremely high price in terms of suffering; around 600,000 soldiers died. About 100,000 of these deaths were caused by diseases, mainly infectious ones. The casualties accounted for over one million cases. Epidemics of cholera and petechial typhus were recorded as well as an increase in morbidity due to tuberculosis and malaria, which had shown some minor epidemiological reduction in several regions of Italy during the years preceding the Great War. A large number of soldiers acquired respiratory tract and brain infections. Severe limb infections were due to war wounds, but also to a novel disorder called &lquo;trench foot&lquo;, In a context of general hygienic decay, death and stress linked to massive bombing, severe psychiatric disorders were observed. They were called &lquo;shell shock&lquo; in English (and known in Italy as &lquo;the wind of the howitzer&lquo;). The patients suffering from the above psychiatric disorders were considered simulators by the great majority of psychiatrists, who largely believed such soldiers wanted to avoid active combat. They were subjected to electric shocks and later sent back to the war front or to a mental hospital in the most severe cases. In some dramatic occurrences, like at the time of the Caporetto defeat, a substantial number of soldiers were dealt rough justice in front of firing squads under the suspicion of desertion.
Yet World War I, with its dramatic load of suffering, forced the medical environment to develop extremely innovative techniques and research applied to clinical practice. During the decades to follow, such efforts yielded major results in the field of pharmacology: studies which led to the discovery of the first antibiotics were set in motion.
Letters to the editor
Sanitary alert: acute gastroenteritis associated with house-fly infestation after heavy rainfall in Karachi, Pakistan
Baloch Mariam,
Tarar Shafaq,
Taimur Sarah
Not available
Erratum
ERRATUM Drug-drug interactions in anti-HCV therapy: a comparison among options available in Italy
Di Perri Giovanni,
Cariti Giuseppe
Erratum Following publication of the original article (Le Infezioni in Medicina, 2019, vol:27 (4):pp:239-250) we became aware of the following errors :
In table 3a, pag 245, the interaction between GLE/PIB and Omeprazole does not require dosage adjustments and the correct recommendation is A (allowed) instead of NR (not recommended). The original explanation in the text is correct.
