Antimicrobial Stewardship in Low- and Middle-Income Countries

Infection Prevention and Safety in Low and Middle Income Countries (C Bardossy, Section Editor)
  • 23 Downloads
Part of the following topical collections:
  1. Topical Collection on Infection Prevention and Safety in Low and Middle Income Countries

Abstract

Purpose of review

Antimicrobial stewardship (AMS) is one of the core elements of infection prevention and control, but in many resource-limited countries its implementation is absent or suboptimal. There is inadequate information on the best model for an AMS program. AMS should be adapted to each region according to sociocultural dimensions, financing, and antimicrobial resistance.

Recent findings

Many of antimicrobials prescribed in hospitals are inappropriate or unnecessary, increasing the risk of adverse reactions and antimicrobial resistance. AMS programs are of essential benefits in low- and middle-income countries (LMIC) where high level of antimicrobial resistance is reported. Low-quality and/or counterfeit antimicrobials and self-medication are known problems in LMIC opposing to adequate AMS programs.

Summary

AMS programs must be present in all scenarios and should be context- and culture-adapted, balancing effectiveness and cost of different strategies. Analysis of AMS programs should be done at each institution of the country and its health system. Diagnostic algorithms and treatment guidelines should be readily available and should be context adapted based on local epidemiology and bacterial resistance. Multidisciplinary groups should be created to improve AMS in each region, including human health, veterinary, and agriculture.

Keywords

Antimicrobial stewardship Low- and middle-income countries Emerging economies Antimicrobial resistance Infection prevention and control Patient safety 

Notes

Compliance with ethical standards

Conflict of interest

Dr. Dapás declares that he has no conflict of interest.

Dr. Quirós has received personal fees from 3M Company, GSK, and MSD.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Tan SY, Tatsumura Y. Alexander Fleming (1881–1955): discoverer of penicillin. Singap Med J. 2015;56(7):366–7.  https://doi.org/10.11622/smedj.2015105.CrossRefGoogle Scholar
  2. 2.
    Shlaes DM, Gerding DN, Jr John JF, Craig WA, Bornstein DL, Duncan RA, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis. 1997;25(3):584–99.  https://doi.org/10.1086/513766.CrossRefPubMedGoogle Scholar
  3. 3.
    Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–177.  https://doi.org/10.1086/510393.CrossRefPubMedGoogle Scholar
  4. 4.
    Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR. Morbidity and Mortality Weekly Report. 2014;63.Google Scholar
  5. 5.
    •• TF Barlam, SE Cosgrove, L Abbo, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;e1-e27. Evidence-based and strong society’s recommendations for implementing an antibiotic stewardship program in inpatient populations.Google Scholar
  6. 6.
    • CDC. Core Elements of Hospital Antimicrobial Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at: https://www.cdc.gov/antibiotic-use/healthcare/implementation/coreelements.html.Recommendations for the bases of hospital antibiotic stewardship programs and all its components.
  7. 7.
    The World Bank. Available at: http://data.worldbank.org/about/country-andlending-groups. Accessed July 3, 2017.
  8. 8.
    Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165–228.  https://doi.org/10.1007/s00134-012-2769-8.CrossRefPubMedGoogle Scholar
  9. 9.
    Camins BC, King MD, Wells JB, Googe HL, Patel M, Kourbatova EV, et al. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol. 2009;30(10):931–8.  https://doi.org/10.1086/605924.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Ingram PR, Seet JM, Budgeon CA, Murray R. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Intern Med J. 2012;42(6):719–21.  https://doi.org/10.1111/j.1445-5994.2012.02809.x.CrossRefPubMedGoogle Scholar
  11. 11.
    Levin PD, Idrees S, Sprung CL, Weissman C, Weiss Y, Moses AE, et al. Antimicrobial use in the ICU: indications and accuracy—an observational trial. J Hosp Med. 2012;7(9):672–8.  https://doi.org/10.1002/jhm.1964.CrossRefPubMedGoogle Scholar
  12. 12.
    Patel SJ, Oshodi A, Prasad P, Delamora P, Larson E, Zaoutis T, et al. Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 step campaign to prevent antimicrobial resistance. Pediatr Infect Dis J. 2009;28(12):1047–51.  https://doi.org/10.1097/INF.0b013e3181b12484.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Quirós R, Clara L, Marcó del Pont J, et al. Evaluación del patrón de consumo de antimicrobianos en un hospital de alta complejidad: análisis de los costos y de la racionalidad de la indicación. Congreso Nacional de Medicina IV, XXI Jornadas Nacionales Interresidencias de Clínica Médica. Noviembre 1994, Buenos Aires, Argentina.Google Scholar
  14. 14.
    Quirós R, Clara L, Marcó del Pont, et al. Estudio multicéntrico de infección hospitalaria: análisis del patrón de consumo de antimicrobianos. Congreso Nacional de Medicina V, XXII Jornadas Nacionales de Interresidencias de Clínica Médica organizado por la Sociedad Argentina de Medicina. 1995, Rosario, Argentina.Google Scholar
  15. 15.
    Saleh N, Awada S, Awwad R, Jibai S, Arfoul C, Zaiter L, et al. Evaluation of antibiotic prescription in the Lebanese community: a pilot study. Infect Ecol Epidemiol. 2015;5:27094.CrossRefPubMedGoogle Scholar
  16. 16.
    Okeke I, Laxminarayan R, Bhutta Z, et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect Dis. 2005;5(8):481–93.  https://doi.org/10.1016/S1473-3099(05)70189-4.CrossRefPubMedGoogle Scholar
  17. 17.
    Okeke I, Klugman K, Bhutta Z, et al. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect Dis. 2005;5(9):568–80.  https://doi.org/10.1016/S1473-3099(05)70217-6.CrossRefPubMedGoogle Scholar
  18. 18.
    Okeke IN, Peeling RW, Goossens H, Auckenthaler R, Olmsted SS, de Lavison JF, et al. Diagnostics as essential tools for containing antibacterial resistance. Drug Resist Updat. 2011;14(2):95–106.  https://doi.org/10.1016/j.drup.2011.02.002.CrossRefPubMedGoogle Scholar
  19. 19.
    Berkelman, R; Cassell G; Specter S; Hamburg M; Klugman K. The “Achilles heel” of global efforts to combat infectious diseases. Clin Infect Dis United States. 2006;1503–1504.Google Scholar
  20. 20.
    Alshammari TM, Larrat EP, Morrill HJ, Caffrey AR, Quilliam BJ, Laplante KL. Risk of hepatotoxicity associated with fluoroquinolones: a national case control safety study. Am J Health Syst Pharm. 2014;71(1):37–43.  https://doi.org/10.2146/ajhp130165.CrossRefPubMedGoogle Scholar
  21. 21.
    Boggs SR, Cunnion KM, Raafat RH. Ceftriaxone-induced hemolysis in a child with Lyme arthritis: a case for antimicrobial stewardship. Pediatrics. 2011;128(5):e1289–92.  https://doi.org/10.1542/peds.2010-1570.CrossRefPubMedGoogle Scholar
  22. 22.
    Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012;67(3):742–8.  https://doi.org/10.1093/jac/dkr508.CrossRefPubMedGoogle Scholar
  23. 23.
    Lapi F, Wilchesky M, Kezouh A, Benisty JI, Ernst P, Suissa S. Fluoroquinolones and the risk of serious arrhythmia: a population-based study. Clin Infect Dis. 2012;55(11):1457–65.  https://doi.org/10.1093/cid/cis664.CrossRefPubMedGoogle Scholar
  24. 24.
    Huttner A, Harbarth S, Carlet J, Cosgrove S, Goossens H, Holmes A, et al. Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum. Antimicrob Resist Infect Control. 2013;2(1):31.  https://doi.org/10.1186/2047-2994-2-31.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States. Atlanta, GA: CDC; 2013. p. 2013.Google Scholar
  26. 26.
    World health organization the evolving threat of antimicrobial resistance: options for action. http://www.who.int/patientsafety/implementation/amr/publication/en/.
  27. 27.
    WHO. Global Action plan on antibiotic resistance. Resolution WH68.17. World Health Organization, Geneva; 2015.Google Scholar
  28. 28.
    •• World Health Organization. Worldwide country situation analysis: response to antimicrobial resistance. 2015. WHO antimicrobial resistance analysis of each region, regarding national plans, surveillance and laboratory capacity, access to quality-assured antimicrobials, use of antimicrobials, public awareness and infection prevention, and control programs.Google Scholar
  29. 29.
    Lynch P, Pittet D, Borg MA, Mehtar S. Infection control in countries with limited resources. J Hosp Infect. 2007;65(S2):148–50.  https://doi.org/10.1016/S0195-6701(07)60033-4.CrossRefPubMedGoogle Scholar
  30. 30.
    Mathew AG, Cissell R, Liamthong S. Antibiotic resistance in bacteria associated with food animals: a United States perspective of livestock production. Foodborne Pathog Dis. 2007;4(2):115–33.  https://doi.org/10.1089/fpd.2006.0066.CrossRefPubMedGoogle Scholar
  31. 31.
    Levy SB, FitzGerald GB, Macone AB. Spread of antibiotic-resistant plasmids from chicken to chicken and from chicken to man. Nature. 1976;260(5546):40–2.  https://doi.org/10.1038/260040a0.CrossRefPubMedGoogle Scholar
  32. 32.
    Webster P. Poultry, politics, and antibiotic resistance. Lancet. 2009;374(9692):773–4.  https://doi.org/10.1016/S0140-6736(09)61578-6.CrossRefPubMedGoogle Scholar
  33. 33.
    Estrategia Argentina para el Control de la Resistencia Antimicrobiana. Ministerio de Salud y Ministerio de Agricultura, Ganadería y Pesca. Resolución Conjunta 834/2015 y 391/2015.Google Scholar
  34. 34.
    Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, et al. Effect of handwashing on child health: a randomised controlled trial. Lancet. 2005;366(9481):225–33.  https://doi.org/10.1016/S0140-6736(05)66912-7.CrossRefPubMedGoogle Scholar
  35. 35.
    Dagan R. Impact of pneumococcal conjugate vaccine on infections caused by antibiotic-resistant Streptococcus pneumoniae. Clin Microbiol Infect. 2009;15(suppl 3):16–20.  https://doi.org/10.1111/j.1469-0691.2009.02726.x.CrossRefPubMedGoogle Scholar
  36. 36.
    Pletz MW. Pneumococcal vaccine: protection of adults and reduction of antibiotic Resistence by vaccination of children with a conjugated vaccine. Med Monatsschr Pharm. 2011;34(6):201–5 (in German).PubMedGoogle Scholar
  37. 37.
    Song JH, Dagan R, Klugman KP, Fritzell B. The relationship between pneumococcal serotypes and antibiotic resistance. Vaccine. 2012;30(17):2728–37.  https://doi.org/10.1016/j.vaccine.2012.01.091.CrossRefPubMedGoogle Scholar
  38. 38.
    Porco TC, Gebre T, Ayele B, House J, Keenan J, Zhou Z, et al. Effect of mass distribution of azithromycin for trachoma control on overall mortality in Ethiopian children: a randomized trial. JAMA. 2009;302(9):962–8.  https://doi.org/10.1001/jama.2009.1266.CrossRefPubMedGoogle Scholar
  39. 39.
    Skalet AH, Cevallos V, Ayele B, Gebre T, Zhou Z, Jorgensen JH, et al. Antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae: a cluster-randomized clinical trial. PLoS Med. 2010;7(12):e1000377.  https://doi.org/10.1371/journal.pmed.1000377.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    UNICEF. Pneumonia and diarrhoea: tackling the deadliest diseases for the world’s poorest children. New York, NY: United Nations Children’s Fund, 2012. http://www.unicef.org/eapro/Pneumonia_and_Diarrhoea_Report_2012.pdf.
  41. 41.
    Togoobaatar G, Ikeda N, Ali M, Sonomjamts M, Dashdemberel S, Mori R, et al. Survey of non-prescribed use of antibiotics for children in an urban community in Mongolia. Bull World Health Organ. 2010;88(12):930–6.  https://doi.org/10.2471/BLT.10.079004.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Okumura J, Wakai S, Umenai T. Drug utilisation and self-medication in rural communities in Vietnam. Soc Sci Med. 2002;54(12):1875–86.  https://doi.org/10.1016/S0277-9536(01)00155-1.CrossRefPubMedGoogle Scholar
  43. 43.
    Bi P, Tong SL, Parton KA. Family self-medication and antibiotics abuse for children and juveniles in a Chinese city. Soc Sci Med. 2000;50(10):1445–50.  https://doi.org/10.1016/S0277-9536(99)00304-4.CrossRefPubMedGoogle Scholar
  44. 44.
    Thuan NT, Lofgren C, Lindholm L, Chuc NT. Choice of healthcare provider following reform in Vietnam. BMC Health Serv Res. 2008;8(1):162.  https://doi.org/10.1186/1472-6963-8-162.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Hofstede G, Hofstede GJ, Minkov M. Cultures and organizations: software of the mind. New York: McGraw-Hill; 2010.Google Scholar
  46. 46.
    Borg M. Cultural determinants of infection control behaviour: understanding drivers and implementing effective change. J Hosp Infect. 2014;86(3):161–8.  https://doi.org/10.1016/j.jhin.2013.12.006.CrossRefPubMedGoogle Scholar
  47. 47.
    • Cheng A, Worth L. Cultural dimensions relevant to antimicrobial stewardship: the contribution of individualism and power distance to perioperative prescribing practices in European hospitals. Healthcare Infect. 2015;20(3–4):124–7. This article reflects the importance of Hofstede’s cultural dimensions on inadequate surgical prophylaxis. The impact of sociocultural factors require further consideration in formulating targeted interventions for improved prescribing practices.  https://doi.org/10.1071/HI15010.CrossRefGoogle Scholar
  48. 48.
    Borg M. National cultural dimensions as drivers of inappropriate ambulatory care consumption of antibiotics in Europe and their relevance to awareness campaigns. J Antimicrob Chemother. 2012;67(3):763–7.  https://doi.org/10.1093/jac/dkr541.CrossRefPubMedGoogle Scholar
  49. 49.
    Harbarth H, Samore MH. Antimicrobial resistance determinants and future control. Emerg Infect Dis. 2005;11(6):794–801.  https://doi.org/10.3201/eid1106.050167.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Schwaber MJ, Lev B, Israeli A, Solter E, Smollan G, Rubinovitch B, et al. Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention. Clin Infect Dis. 2011;52(7):1–8.CrossRefGoogle Scholar
  51. 51.
    Maltezou HC, Kontopidou F, Dedoukou X, Katerelos P, Gourgoulis GM, Tsonou P, et al. Action plan to combat infections due to carbapenem-resistant, gram-negative pathogens in acute-care hospitals in Greece. J Global Antimicrob Resist. 2014;2(1):11–6.  https://doi.org/10.1016/j.jgar.2013.06.002.CrossRefGoogle Scholar
  52. 52.
    Basco LK. Molecular epidemiology of malaria in Cameroon. XIX. Quality of antimalarial drugs used for self-medication. Am J Trop Med Hyg. 2004;70(3):245–50.PubMedGoogle Scholar
  53. 53.
    Rudolf PM, Bernstein IB. Counterfeit Drugs. N Engl J Med. 2004;350(14):1384–6.  https://doi.org/10.1056/NEJMp038231.CrossRefPubMedGoogle Scholar
  54. 54.
    Pincock S. WHO tries to tackle problem of counterfeit medicines in Asia. BMJ. 2003;327:1126.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Cameron A, Mantel-Teeuwisse AK, Leufkens HG, Laing RO. Switching from originator brand medicines to generic equivalents in selected developing countries: how much could be saved? Value Health. 2012;15(5):664–73.  https://doi.org/10.1016/j.jval.2012.04.004.CrossRefPubMedGoogle Scholar
  56. 56.
    Dondorp A, Nosten F, Stepniewska K, Day N, White N, the South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group. Artesunate versus quinine for treatment of severe falciparum malaria: a randomized trial. Lancet. 2005;366(9487):717–25.  https://doi.org/10.1016/S0140-6736(05)67176-0.CrossRefPubMedGoogle Scholar
  57. 57.
    Dondorp AM, Fanello CI, Hendriksen IC, the AQUAMAT group, et al. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomized trial. Lancet. 2010;376:1647–57.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    WHO. Prequalification program: a United Nations program managed by WHO. Geneva: World Health Organization, 2010. http://apps.who.int/prequal.
  59. 59.
    Projan SJ. Why is big pharma getting out of antibacterial drug discovery? Curr Opin Microbiol. 2003;6(5):427–30.  https://doi.org/10.1016/j.mib.2003.08.003.CrossRefPubMedGoogle Scholar
  60. 60.
    Sertkaya A, Eyraud J, Birkenbach A, et al. Analytical Framework for Examining the Value of Antibacterial Products. 2014. http://aspe.hhs.gov/sp/reports/2014/antibacterials/rpt_antibacterials.cfm.
  61. 61.
    Stewart JJ, Allison PN, Johnson RS. Putting a price on biotechnology. Nat Biotechnol. 2001;19(9):813–7.  https://doi.org/10.1038/nbt0901-813.CrossRefPubMedGoogle Scholar
  62. 62.
    • Årdal C, Outterson K, Hoffman SJ, Ghafur A, Sharland M, Ranganathan N, et al. International cooperation to improve access to and sustain effectiveness of antimicrobials. Lancet Series. 2015;387(10015):296–307.  https://doi.org/10.1016/S0140-6736(15)00470-5. Coordinated efforts are required to maintain antimicrobial effectiveness, involving not only World Health Organization, but also other institutions that regulates antimicrobial use in agriculture and at a global level.CrossRefGoogle Scholar
  63. 63.
    •• Mendelson M, Røttingen JA, Gopinathan U, Hamer DH, Wertheim H, Basnyat B, et al. Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries. Lancet Series. 2015;387(10014):188–98.  https://doi.org/10.1016/S0140-6736(15)00547-4.Adequate antimicrobial use in low- and middle-income countries represents a result of access to drugs, assured quality of them, access to diagnostics, and evidence-based treatment algorithms.CrossRefGoogle Scholar
  64. 64.
    Yeboah-Antwi K, Pilingana P, Macleod WB, Semrau K, Siazeele K, Kalesha P, et al. Community case management of fever due to malaria and pneumonia in children under five in Zambia: a cluster randomized controlled trial. PLoS Med. 2010;7(9):e1000340.  https://doi.org/10.1371/journal.pmed.1000340.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Shakely D, Elfving K, Aydin-Schmidt B, Msellem MI, Morris U, Omar R, et al. The usefulness of rapid diagnostic tests in the new context of low malaria transmission in Zanzibar. PLoS One. 2013;8(9):e72912.  https://doi.org/10.1371/journal.pone.0072912.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Leibovici L, Paul M, Ezra O. Ethical dilemmas in antibiotic treatment. J Antimicrob Chemother. 2012;67(1):12–6.  https://doi.org/10.1093/jac/dkr425.CrossRefPubMedGoogle Scholar
  67. 67.
    WHO. WHO Global Strategy for containment of antibiotic resistance. WHO/CSR/DRS/2001.2, World Health Organization, Geneva, 200113, WHO. Global Action plan on antibiotic resistance. Secretariat’s report A68/20. World Health Organization, Geneva, 2015.Google Scholar
  68. 68.
    Holloway KA, Rosella L, Henry D. The impact of WHO essential medicines policies on inappropriate use of antibiotics. PLoS ONE. 2016;11(3):e0152020.  https://doi.org/10.1371/journal.pone.0152020.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543.Google Scholar
  70. 70.
    Malani AN, Richards PG, Kapila S, Otto MH, Czerwinski J, Singal B. Clinical and economic outcomes from a community hospital’s antimicrobial stewardship program. Am J Infect Control. 2013;41(2):145–8.  https://doi.org/10.1016/j.ajic.2012.02.021.CrossRefPubMedGoogle Scholar
  71. 71.
    Quirós R, Martinez C, Clara L, et al. Combined monitoring of the hospital use of antimicrobials drugs: use of defined daily dose as a unit of measurement for total drug utilization. The Seventh Annual Meeting of the Society for Healthcare Epidemiology of America. Abril 1997, Saint Louis, Missouri, USA.Google Scholar
  72. 72.
    Bantar C, Sartori B, Vesco E, Heft C, Saul M, Salamone F, et al. A hospital wide intervention program to optimize the quality of antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance. Clin Infect Dis. 2003;37(2):180–6.  https://doi.org/10.1086/375818.CrossRefPubMedGoogle Scholar
  73. 73.
    GARP-Viet Nam working group situation analysis: antibiotic use and resistance in Viet Nam.http://www.cddep.org/publications/situation_analysis_antibiotic_use_and_resistance_vietnam.
  74. 74.
    • RE Quirós, A Vila, A Manzur, et al. Factores asociados con el nivel de desarrollo de los programas para la gestión del uso de antimicrobianos (PROAs) en centros asistenciales de la República Argentina. Proyecto PROA, Argentina. XVII Congreso de la Sociedad Argentina de Infectología, Mar del Plata, Argentina, 2017. Multicenter project on antimicrobial stewardship program implementation in institutions from Argentina.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Infectious Diseases DivisionHospital Italiano de MendozaMendozaArgentina
  2. 2.Infectious Diseases DivisionHospital Central de MendozaMendozaArgentina
  3. 3.Gerente General, Clínica Ángel FoianiniSanta Cruz de la SierraBolivia

Personalised recommendations