Infection in ICU:Infection in ICU:LRTI, UTI, Blood Stream, Skin, & GITLRTI, UTI, Blood Stream, Skin, & GIT
Iman Galal, MDIman Galal, MDAss. Professor of Pulmonary Medicine/Ain Shams UniversityAss. Professor of Pulmonary Medicine/Ain Shams University
E-mail: [email protected]: [email protected]
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Why is an ICU Patient at Risk ??
04/07/23
► Most Sick patients (multiple diagnoses, multi-organ failure,
immunocompromised, septic, & trauma)
► Move less
► Malnourished
► More obtunded (Glasgow coma scale)
► Associated comorbidity e.g., DM, CHF
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Why is ICU Care Invasive ??
04/07/23
► More invasive lines & procedures
► Longer length of stay
► More IV & parenteral drugs
► More tube feeding
► More parenteral nutrition
► More ventilation
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Nosocomial Infections: Definition & BurdenDefinition & Burden
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► 5-10% of patients admitted to acute care hospitals acquire infections
► 2 million patients/year
► ¼ of nosocomial infections occur in ICUs
► 90,000 deaths/year
► Attributable annual cost: $4.5 –$5.7 billion
► A third of nosocomial infections are preventable.
► Hand washing is the best preventative measure against the spread of
infection; gloves are not a substitute for hand washing.
► Inadequate antibiotic therapy is associated with poor outcome and
emergence of bacterial resistance.
Weinstein RA. Emerg Infect Dis 1998;4:416-420.Jarvis WR. Emerg Infect Dis 2001;7:170-173.
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Major Nosocomial Infections
► Urinary tract infection
► Hospital-acquired & Ventilator-associated Pneumonia
► Bloodstream infection
► GIT infection
► Skin infection
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Major Nosocomial Infections: Common ICU PathogensCommon ICU Pathogens
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Nosocomial Urinary Tract Infection
► Most common hospital-acquired infection (40% of all nosocomial
infections).
► 1 million cases of nosocomial UTI per year in the US.
► Of nosocomial infections; lowest mortality & cost.
► > 80% associated with urinary catheter.
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Nosocomial Urinary Tract Infection
► 25% of hospitalized patients will have a urinary catheter for part of their
stay
► 40-50% of these patients do not have a valid indication for urinary
catheter placement
► Incidence of nosocomial UTI is ~5% per catheterized day
► Virtually all patients develop bacteriuria by 30 days of catheterization
► Of patients who develop bacteriuria, 3% will develop bacteremia
► Vast majority of catheter-associated UTIs are silent, but these comprise
the largest pool of antibiotic-resistant pathogens in the hospital
Safdar N et al. Current Infect Dis Reports 2001;3:487-495.
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Catherarization: Skill, Size, Capacity & Application Skill, Size, Capacity & Application
► Insertion of a urinary catheter is an
essential medical skill.
► Catheters are sized in units called
French, where one French equals
1/3 of 1 mm.
► Catheters vary from 12 (small) FR
to 26 (large) FR in size.
► One should check the capacity of
each catheter balloon.
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Catherarization: PreparationPreparation
► Most common mode of transmission of pathogens is via hands.
► Hand washing protect the patient against harmful germs carried on the
hands or present on his/her own skin & protect the physician from
harmful germs
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Hand Hygiene Preparations: EfficacyEfficacy
Good Better Best
Plain Soap Antimicrobial soap
Alcohol-based handrub
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ICU Infection: Frequent Sites & Risk FactorsFrequent Sites & Risk Factors
LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationMechanical ventilation
AspirationAspirationNasogastric tubeNasogastric tube
Central nervous system depressantsCentral nervous system depressantsAntibiotics and anti-acidsAntibiotics and anti-acids
Prolonged health-care facilities stayProlonged health-care facilities stayMalnutritionMalnutrition
Advanced ageAdvanced ageSurgerySurgery
ImmunodeficiencyImmunodeficiency
13%
BLOOD INFECTIONSVascular catheterVascular catheter
Neonatal ageNeonatal ageCritical care Critical care
Severe underlying diseaseSevere underlying diseaseNeutropeniaNeutropenia
ImmunodeficiencyImmunodeficiencyNew invasive technologiesNew invasive technologies
Lack of training and supervisionLack of training and supervision14%
SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxisInadequate antibiotic prophylaxis
Incorrect surgical skin preparationIncorrect surgical skin preparationInappropriate wound care Inappropriate wound care
Surgical intervention durationSurgical intervention durationType of woundType of wound
Poor surgical asepsisPoor surgical asepsisDiabetesDiabetes
Nutritional stateNutritional stateImmunodeficiencyImmunodeficiency
Lack of training and supervisionLack of training and supervision17%
URINARY TRACT INFECTIONSUrinary catheterUrinary catheter
Urinary invasive proceduresUrinary invasive proceduresAdvanced ageAdvanced age
Severe underlying diseaseSevere underlying diseaseUrolitiasisUrolitiasisPregnancyPregnancyDiabetesDiabetes
34%
Most common sites of health care-associated infection and the risk factors
underlying the occurrence of
infections
LACK OF HAND
HYGIENE
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► Adequate hand washing with water & soap requires 40–60 seconds
► Average time usually adopted by health-care workers is < 10 seconds
► Alcohol-based hand rubbing takes 20–30 seconds
Hand Washing: Time ObstacleTime Obstacle
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Hand Hygiene: The 5 Moments ApproachThe 5 Moments Approach
14\
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Hand Washing: TechniqueTechnique
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► Skin irritation
► Inaccessible hand washing facilities
► Wearing gloves
► Too busy
► Being a physician
► Lack of hand hygiene promotion
► Lack of role model
Hand Washing: Why Not ??!Why Not ??!
“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381
Estimated Compliance < 50%
Estimated Compliance < 50%
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► Education
► Routine observation & feedback
► Engineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs available
► Patient education
Hand Washing: Successful Promotion Successful Promotion
“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381
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Catherarization: DisinfectionDisinfection
► Povidone-iodine is currently the most widely used agent for disinfection.
► Chlorhexidine gluconate has been compared to PI with mixed results.
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Nosocomial Urinary Tract Infection: Risk FactorsRisk Factors
► Indwelling Foley catheters Indwelling Foley catheters ► Female gender
► Advanced age
► Other active site of infection
► Diabetes mellitus
► Renal insufficiency
► Duration of catheterization
► Insertion of catheter late in hospitalization
► Presence of ureteral stent
► Disconnection of catheter from drainage tube
► Retrograde flow of urine from drainage bag
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Nosocomial Urinary Tract Infection: ConsequencesConsequences
► Pyelonephritis
► Death from Bacteremia
► Uretheral damage (scarring & strictures)
► Prostatitis & epididymitis
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Nosocomial Urinary Tract Infection: PreventionPrevention
► Avoid catheter when possible & discontinue as soon as possible
► Aseptic insertion by trained physician
► Maintain closed system of drainage
► Ensure dependent drainage
► Minimize manipulation of the system
► Silver coated catheters
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Blood stream infections: Central Venous CatheterizationCentral Venous Catheterization
Indications:Indications:
►IV fluids and drugs
►Blood and blood products
►Total Parenteral Nutrition (TPN)
►Hemodialysis
►Hemodynamic monitoring
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Blood stream infections:Catheter-related bloodstream infectionCatheter-related bloodstream infection
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► Catheter-related bloodstream infection (CRBSI), also called catheter-related
sepsis) is defined as the presence of bacteraemiabacteraemia originating from an I.V. I.V.
catheter.catheter.
► One of the most frequent, lethal & costly complications of CVC.
► CRBSI can originate from peripheral I.V. & intra-arterial cannula (very rare).
► Pulmonary artery catheters have a similar incidence of CRBSI to CVCs;
dialysis catheters appear to have a much higher rate.
► CRBSI occurs in 3% of catheterizations, however, may be as high as 16%.
This represents 2–30 episodes per 1000 catheter days.
► Most common cause of nosocomial bacteraemia.
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Blood stream infections:Organisms causing CRBSIOrganisms causing CRBSI
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Organism %of total
S. aureus 22
Coagulase-negative staphylococcus 37
Yeasts 9.3
Enteric Gram-negative bacilli 12.4
Enterococci and streptococci 4.9
Pseudomonas 5.5
Other 8.9
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Blood stream infections:Risk factorsRisk factors
04/07/23
► Immunosuppression.
► Frequent accessing of the catheter.
► Poor aseptic technique.
► Administration of TPN.
► Subclavian CVCs have the lowest infection rate followed by internal
jugular & femoral catheters.
► Prolonged catheterization.
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Blood stream infections:DiagnosisDiagnosis
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Diagnosis of CRBSI is based on the following:Diagnosis of CRBSI is based on the following:
i. The presence of a CVC.
ii.Signs of catheter insertion site infection.
iii.Clinical symptoms & signs of bacteraemia.
iv.Resolution of the symptoms & signs of bacteraemia after removal of the
suspected CVC.
v.Positive blood culture.
vi.Growth of the same organism from the catheter.
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Blood stream infections:In situ microbiological diagnosisIn situ microbiological diagnosis
04/07/23
Quantitative blood culture:Quantitative blood culture:CRBSI is suggested when the number of microbes from a CVC sample of blood is 5 times that from a simultaneously collected peripheral sample. This is not widely available.
Acridine orange staining of blood taken from the CVC: Acridine orange staining of blood taken from the CVC: Not widely available.
Endoluminal brush sampling:Endoluminal brush sampling:A tiny brush is passed down the catheter lumen & is examined microbiologically by culture.This test has a high sensitivity & specificity but is not widely available.There are concerns about the generation of a bacteraemia caused by organisms dislodgement.
Differential time to positivity:Differential time to positivity:CRBSI is suggested when blood from CVC demonstrates microbial growth at least 2 h earlier than growth is detected in blood collected simultaneously from a peripheral vein.Most currently used automated blood culture systems can readily provide this information.
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Blood stream infections:Prevention GuidelinesPrevention Guidelines
04/07/23
Selection of catheter typeSelection of catheter typeUse a single-lumen catheter unless multiple ports are essentialFor total parenteral nutrition, a dedicated CVC or lumen should be used exclusivelyConsider the use of an antimicrobial impregnated catheter for patients at high risk of CRBSISelection of catheter insertion siteSelection of catheter insertion siteBalance risks of infection against mechanical risks of insertionUse the subclavian route unless contraindicatedConsider the use of peripherally inserted catheters as an alternative to CVCsAseptic technique during insertionAseptic technique during insertionUse optimum insertion technique including sterile gown, gloves and drapesClean the insertion site with alcoholic chlorhexidene gluconate solution (or alcoholic povidone iodine) and allow to dryCatheter & catheter site careCatheter & catheter site careBefore accessing the CVC, disinfect the external surfaces of the catheter hub and connection ports with an aqueous solution of chlorhexidene gluconate or povidone iodine (unless against manufacturer’s recommendations)Use sterile gauze or transparent dressing over the insertion siteCatheter flush solutions should contain anticoagulantReplacement strategiesReplacement strategiesGuidewire exchange is acceptable for malfunctioning catheters if there is no evidence of infection
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Blood stream infections:TreatmentTreatment
04/07/23
► Remove the catheter if CRBSI is suspected.
► If the line is ‘precious’ and/or other access impossible, it may be justifiable to leave the catheter in place & treat medically.
► Some clinicians practice guidewire exchange for ‘precious’ catheters.
► If the removed catheter is proven on microbiological examination to be the source of sepsis then the exchanged catheter is removed & another site selected.
► Antibiotic therapy should be based on culture reports.
► One week’s treatment may be appropriate where the catheter has been removed, 2 weeks if the infection is caused by Staphylococcus aureus or fungi.
► Where deep-seated infection is suspected, further imaging and prolonged antibiotic therapy may be required.
► If microbiological data are not available or treatment is indicated before cultures are complete, blind antibiotic therapy should target the likely pathogens (including resistant Gram-negative organisms and methicillin-resistant S. aureus)
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Hospital Acquired & Ventilator Associated Pneumonia
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► Hospital-acquired pneumonia (HAP) & ventilator associated
pneumonia (VAP), subclassifications of nosocomial pneumonia, are
considered to be the most serious hospital-acquired infections
because of their relatively high associated morbidity & mortality.
► HAP is defined as pneumonia that occurs 48 h after hospital admission
that did not appear to be incubating at the time of admission.
► VAP is pneumonia that arises > 48–72 hrs after endotracheal
intubation.
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HAP & VAP: Risk Factors for MDR PathogensRisk Factors for MDR Pathogens
04/07/23
► Antimicrobial therapy in preceding 90 d
► Current hospitalization of 5 d or more
► High frequency of antibiotic resistance in the ICU
► Immunosuppressive disease and/or therapy
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HAP & VAP: Recommendations for diagnosisRecommendations for diagnosis
04/07/23
► New or progressive pulmonary infiltrate & 2 of fever, leukocytosis, or sputum purulence is most accurate clinical criteriaclinical criteria
► Perform blood cultures
► Cultures for LRT secretions before initiating antimicrobial therapy
► Negative culture result of appropriate LRT specimen in absence of change in antimicrobial therapy in preceding 72 h virtually rules out pyogenic bacterial infection (exception includes Legionella)
► Reliable tracheal aspirate Gram stain can be used to direct initial antimicrobial therapy & may increase the diagnostic value of CPIS
► Quantitative cultures can be performed on endotracheal bronchoscopically or non-bronchoscopically samples
► Modified CPIS of 6 for 3 days is a criterion to select patients at low risk for early discontinuation of empirical therapy of HAP
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Clinical Pulmonary Infection Score (CPIS)
AJRCCM 2000;162:501-511
Score 0 1 2
Temperature ≥ 36.5 & ≤ 38.4 ≥ 38.5 & ≤ 38.9 ≥ 39 & ≤ 36.4
TLC ≥ 4 & ≤ 11 < 4 or > 12
Tracheal Secretions None Non-purulent Purulent
OxygenationPaO2/FIO2 mmHg > 240 or ARDS ≤ 240 & no ARDS
Chest Radiograph No opacity Diffuse (patchy) opacities Localized opacity
Progression of Radiograpgic Opacities No progression Progression (after HF
& ARDS excluded)
Culture of Tracheal Aspirate
Pathogenic bacteria cultured in rare/few
quantities or no growth
Pathogenic bacteria cultured in moderate
or heavy quantity
AJRCCM 2000;162:501-511
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Modified Clinical Pulmonary Infection Score
AJRCCM 2000;162:501-511
Score 0 1 2
Temperature ≥ 36.5 & ≤ 38.4 ≥ 38.5 & ≤ 38.9 ≥ 39 & ≤ 36.4
TLC ≥ 4 & ≤ 11 < 4 or > 12 ≥ 4 & ≤ 11+ band forms ≧ 500
Tracheal Secretions Rare Abundant Abundant + Purulent
OxygenationPaO2/FIO2 mmHg > 240 or ARDS ≤ 240 & no ARDS
Chest Radiograph Infiltrates No opacity Diffuse Localized
Microbiology Negative Positive
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HAP & VAP:Management StrategiesManagement Strategies
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HAP & VAP:Initial Empiric Antibiotic TreatmentInitial Empiric Antibiotic Treatment
04/07/23American Thoracic Society and Infectious Disease Society of America
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HAP & VAP:Initial Empiric Antibiotic TreatmentInitial Empiric Antibiotic Treatment
04/07/23
American Thoracic Society and Infectious Disease Society of America
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HAP & VAP:Initial Empiric Antibiotic TreatmentInitial Empiric Antibiotic Treatment
04/07/23
American Thoracic Society and Infectious Disease Society of America
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HAP & VAP:Duration of Antimicrobial TreatmentDuration of Antimicrobial Treatment
04/07/23
► As short as 7 days, provided that the etiologic pathogen is not
Pseudomonas aeruginosa and that the patient has a good clinical
response
American Thoracic Society and Infectious Disease Society of America
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HAP & VAP: Assessment of Non-respondersAssessment of Non-responders
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Nosocomial Gastrointestinal Tract Infection:
04/07/23
Term Definition
Gastroenteritis A syndrome characterized by gastrointestinal symptoms including nausea, diarrhea, and abdominal discomfort
DiarrheaAbnormal fecal discharge characterized by frequent and/or fluid stool; usually resulting from disease of the small intestine and involving increased fluid and electrolyte loss
DysenteryAn inflammatory disorder of the GIT often associated with blood and pus in the feces and accompanied by symptoms of pain, fever, abdominal cramps; usually resulting from disease of the large intestine
Enterocolitis Inflammation involving the mucosa of both the small and large intestine
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► Shigella: 101-2
► Giardia lamblia: 101-2
► Entamoeba histolytica: 101-2
► Campylobacter jejuni:102-6
► Salmonella: 105
► E. coli: 108
► Vibrio cholerae: 108
Nosocomial GIT: Infectious doses of enteric pathogensInfectious doses of enteric pathogens
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Nosocomial GIT: Toxin ProductionToxin Production
►Neurotoxins (preformed toxin): Bacillus cereus, Clostridium perfringens,
Staphylococcus aureus
►Enterotoxin: Aeromonas species, enterotoxigenic E. coli, Vibrio cholerae
►Cytotoxin: Clostridium difficile, E. coli 0157:H7
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► Minimal invasion: Norwalk virus, Rotavirus, other viruses
► Variable invasion: Aeromonas sp., Campylobacter sp., Salmonella sp.,
Vibrio parahemolyticus
► Severe invasion: Entamoeba histolytica, enteroinvasive E. coli, Shigella
species
Nosocomial GIT: Mucosal InvasionMucosal Invasion
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Nosocomial Gastrointestinal Tract Infection
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Clinical Features of Bacterial Diarrheal Disease
Pathogen IP DurationSymptoms
Diarrhea Vomiting Abdominal Cramps Fever
Salmonella 6 h-2 d 48 h-7 d ++ + - +
Camylobacter 2-11 d 3 d-3 wks +++ - ++ ++
Shigella 1-4 d 2-3 d ++/+++ - + +
Vibrio Cholerae 2-3 d Up to 7 d ++++ + - -
Vibrio Parahemolyticus 8 h-2 d 3 d +/++ + + +
Clostridium Perfringes 8 h-1 d 12 h-1 d ++ - ++ -
Bacillus Cereus diarrhealBacillus Cereus Emetic
8-12 h15 min-4 h
12 h-1 d12 h-2 d
+++
-++ ++ -
Yersinia Enterocolitica 4-7 d 1-2 wks ++ - ++ +
Page 46 Dr Ekta, Microbiology
► Gross & microscopic stool examination
► Stool culture
► Identification tests
► Endoscopy if non-infectious etiology suspected (inflammatory bowel
disease)
► Specimens include: feces, rectal swab, & doudenal aspirate
► Specimens must be delivered to lab within 1 hr
GIT Infection: DiagnosisDiagnosis
Page 47 Dr Ekta, Microbiology
► Direct wet mount: Ova, parasites, & feces leukocytes
► Gram stain: Campylobacter & Vibrio
► Modified Acid Fast: Cryptosporiduim, Isospora
► Trichrome stain: Parasites
► Fluorescent antibody stain: Giardiasis, Cryptosporidiosis, & E coli
► ELISA: Rota virus, Giardia, & Cryptosporidiosis
GIT Infection: Lab DiagnosisLab Diagnosis
Page 48 Dr Ekta, Microbiology
►Simple diarrhea: antibiotics rarely beneficial
►Rehydration – oral vs. IV
►Antiemetics
►Antidiarrheals
Decrease intestinal motility
Diphenoxylate, loperamide, codeine
►+/- Antibiotics (evidence of invasion) e.g., Shigella, Yersinia,
campylobacter, cholera, & giardia
►C. difficile: stop antibiotics and start on metronidazole /
vancomycin
GIT Infection: TreatmentTreatment
THANK YOUTHANK YOU
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