LE GIORNATE LAZIALI
DELL’APPROPRIATEZZA IN MEDICINA DI
LABORATORIO
2^ Edizione
Roma, 20 novembre 2013
ACO San Filippo Neri
Le emoculture: indicazioni di
appropriatezza prescrittiva
indirizzata dal problema diagnostico
Bruno Mariani
[email protected]
RUOLO CLINICO DELLE EMOCOLTURE
L’emocoltura rappresenta un esame di laboratorio
fondamentale per l’identificazione dell’agente eziologico
dal sangue per la diagnosi di infezioni sistemiche, quali
infezioni cardiache come endocarditi e pericarditi,
infezione
da
cateteri
endovascolari,
infezioni
endoaddominali, infezioni della cute e tessuti molli,
permettendo l’instaurazione precoce di una efficace
terapia antimicrobica. Altro vantaggio è il rapporto
beneficio/costo se si tiene conto della gravità delle
condizioni del paziente che viene sottoposto a tale
indagine.
Health Protection Agency (2005). Investigation of blood cultures (for organisms other than
mycobacterium species).National Standard Method BSOP 37 Emissione 5.
http://www.hpastandardmethods.org.uk/pdf_sops.asp.
CLASSIFICATION OF BACTEREMIA
•
•
•
•
Classified by Site of Origin
Classified by Place of Acquisition
Classified by Duration
Classified by Causative Agent
Betts,Chapman,Penn: «A pratical approach to infectious diseases» 2003,
5° Ed.- Philadelphia, USA
CLASSIFICATION BY SITE OF ORIGIN
• Primary Bacteremia
– Blood stream or endovascular bacterial invasion
with no preceding or simultaneous site of
infection with the same microorganism
• Secondary Bacteremia
– Isolation of a microorganism from blood as well
as other site(s)
• Fever of Unknown Origin (FUO)
– Source unknown
July 2013 CDC/NHSN Protocol Clarifications
CDC/NHSN Surveillance Definitions for
Specific Types of Infections
http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
Le batteriemie primarie si realizzano in
assenza di una fonte d’infezione evidente.
(inoculazione diretta)
Secondo le definizioni e le raccomandazioni dei
“Centers for Disease Control and Prevention”
(CDC), le batteriemie primarie comprendono anche
le infezioni che insorgono come complicanza
dovuta alla presenza di catetere vascolare.
July 2013 CDC/NHSN Protocol Clarifications
CDC/NHSN Surveillance Definitions for Specific Types of Infections
Le batteriemie secondarie sono in
relazione a infezioni presenti in altri siti
anatomici (polmoniti, infezioni urinarie,
ferite infette, ascessi, etc).
Ne consegue che lo stesso microrganismo
e’ presente sia a livello del sito di infezione
che nel sangue.
July 2013 CDC/NHSN Protocol Clarifications
CDC/NHSN Surveillance Definitions for Specific Types of Infections
La pseudobatteriemia
è definita come la presenza di un’emocoltura positiva per
uno o più microrganismi la cui crescita non si correla con
l’evidenza clinica. Questa condizione è spesso chiamata
“contaminazione”.
Il riconoscimento delle pseudobatteriemie è
estremamente importante in quanto fuorvianti per il
paziente perche’ causa di ulteriori prelievi di sangue ,
terapie antibiotiche inutili e una spesa sanitaria inutile.
Reese and Betts, 2003, 5° Ed.- Philadelphia, USA
CLASSIFICATION BY PLACE OF ACQUISITION
• Community-acquired
– Defined as a positive blood culture taken on or
within 48 hours of admission
• Health-care acquired/Nosocomial
– Defined as occurring 72 hours post admission
July 2013 CDC/NHSN Protocol Clarifications
CDC/NHSN Surveillance Definitions for Specific Types of Infections
CLASSIFICATION BY DURATION
• Transient
– Comes and goes
– Usually occurs after a procedural manipulation
(ex. Infected tissues, Dental procedures)
• Intermittent
– Can occur from abscesses at some body site that
is “seeding” the blood
• Continuous Bacteremia
– Organisms from an intravascular source that are
consistently present in bloodstream
Microbiological Findings and BSIs • CID 2009:48 (Suppl 4) • S239
Red and green arrows indicate the presence and absence, respectively, of bacteria in blood
cultures obtained at different time points (in minutes, unless hours [h] is specified).
Microbiological Findings and BSIs • CID 2009:48 (Suppl 4) • S239
(Engineering, Montana State University-Bozeman)
Common sites of biofilm infection Once biofilm reach
the bloodstream they can spread to any moist surface
of the human body.
The biofilm life cycle in three steps: attachment, growth
of colonies (development), and periodic detachment of
planktonic cells
Intermittent Bacteremia
Center for Biofilm Engineering, Montana State University-Bozeman
Otitis media, or inflammation of the
inner ear, caused by biofilm
Center for Biofilm Engineering, Montana State University-Bozeman
CLASSIFICATION BY CAUSATIVE AGENT
•
•
•
•
•
Gram positive bacteremia
Gram negative bacteremia
Anaerobic bacteremia
Polymicrobial bacteremia
Invasive candidiasis
Reese and Betts, 2003, 5° Ed.- Philadelphia, USA
Bacteremia Complications
• Septic shock
– Results from body’s reactions to bacterial
bi-products
• Endotoxins: lipopolysaccharide
• Exotoxins
– Disrupts many body functions
• Hemodynamic changes, decreased tissue
perfusion and compromised organ & tissue
function
SCCM/ACCP/ Consensus Conference. Definitions for sepis and organ failure 1992.
SIRS
La SIRS (Sindrome da Risposta Infiammatoria Sistemica)
definisce la risposta infiammatoria aspecifica dell’organismo
caratterizzata da cause infettive e non infettive che
determinano la liberazione di sostanze endogene: i mediatori
infiammatori. La diagnosi di SIRS richiede la presenza di almeno
due dei seguenti segni clinici:
 temperatura > 38 °C o < 36 °C
 frequenza cardiaca > 90 bpm
 frequenza respiratoria > 20 apm o PaCO2 < 32 mmHg
 numero di globuli bianchi > 12.000/mm3, < 4.000/mm3 o
presenza > 10% di forme immature (band)
SCCM/ACCP/ Consensus Conference. Definitions for sepis and organ failure 1992.
SEPSI
E’ caratterizzata dalla massiccia produzione di
elevate quantità di fattori infiammatori
(PGs, TNFs, IL1, IL6, IL8, IL12)
Le citochine proinfiammatorie innescano:
• alterazione degli endoteli vascolari con collasso
ipotensivo (sepsi ipotensiva)
• la cascata della coagulazione con la formazione di diffuse
coagulazioni intravasali (DIC: disseminated intravascular
coagulation)
• estesi fatti emorragici con la grave compromissione di
diversi organi (Shock settico) ed effetti fatali per il
paziente
Mosnier at al. Blood 2007
Critical Care Medicine- February 2013 • Volume 41 • Number 2
Table 5. Recommendations: Initial Resuscitation and Infection Issues
B. Screening for Sepsis and Performance Improvement
1. Routine screening of potentially infected seriously ill patients for severe sepsis to
allow earlier implementation of therapy (grade 1C).
2. Hospital–based performance improvement efforts in severe sepsis (UG).
C. Diagnosis
1. Cultures as clinically appropriate before antimicrobial therapy if no significant
delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of
blood cultures (both aerobic and anaerobic bottles) be obtained before
antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn
through each vascular access device, unless the device was recently (<48 hrs)
inserted (grade 1C).
2. Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan
antibody assays (2C), if available and invasive candidiasis is in differential
diagnosis of cause of infection.
3. Imaging studies performed promptly to confirm a potential source of infection
(UG).
Critical Care Medicine- February 2013 • Volume 41 • Number 2
SOURCE CONTROL
1. We recommend that a specific anatomical diagnosis of infection requiring
consideration for emergent source control (eg, necrotizing soft tissue
infection, peritonitis, cholangitis, intestinal infarction) be sought and
diagnosed or excluded as rapidly as possible, and intervention be
undertaken for source control within the first 12 hr after the diagnosis is
made, if feasible (grade 1C).
4. If intravascular access devices are a possible source of severe sepsis or
septic shock, they should be removed promptly after other vascular access
has been established (UG).
Critical Care Medicine- February 2013 • Volume 41 • Number 2
EVOLUZIONE SEPSI:
SHOCK SETTICO
Termine che definisce una serie di eventi
fisiopatologici ai danni del sistema
cardiocircolatorio che determinano la
sindrome da insufficienza multipla di organi
(MOFS) che può provocare il decesso del
paziente.
SCCM/ACCP/ Consensus Conference. Definitions for sepis and organ failure 1992.
Bone et al. Chest 1992;101:1644
Le dimensioni del problema
Casi accertati stabiliscono che in tutto il mondo l'incidenza di sepsi è 1,8 milioni di
casi ogni anno, ma questo numero è sottostimato per una controversa diagnosi che
prevede diversi criteri di valutazione nei differenti paesi.
“Surviving Sepsis Campaign” stima che, con una incidenza del 3 ‰, il numero
reale dei casi ogni anno raggiunge i 18 milioni con un tasso di mortalità di quasi il
30% diventando cosi’ una delle principali cause di morte *1,2+. L'incidenza è
destinata ad aumentare con l'invecchiamento della popolazione, essendo gli
anziani i più colpiti [1].
I costi della sepsi sono in media US $ 22 000 per paziente e il suo trattamento ha
un grande impatto sulle risorse finanziarie degli ospedali: negli Stati Uniti ammonta
complessivamente a circa 16,7 miliardi dollari ogni anno [1]. Il costo del
trattamento di un paziente con sepsi ricoverato in ICU è sei volte maggiore di
quella di un paziente senza sepsi [3].
1. Angus DC, et all: Epidemiology of severe sepsis in the United States: analysis of incidence,
outcome, and associated costs of care. Crit Care Med 2001, 29:1303-1310.
2. Hoyert DL, Anderson RN: Age-adjusted death rates: trend data based on the year 2000 standard
population. Natl Vital Stat Rep 2001, 49:1-6.
3. Edbrooke DL, et all: The patient-related costs of care for sepsis patients in a United Kingdom adult
general intensive care unit. Crit Care Med 1999, 27:1760-1767.
Mortalità per sepsi in Italia
In uno studio epidemiologico pan-Europeo* del 2006, la
mortalità intraospedaliera dei pazienti con sepsi grave/shock
settico nelle 24 ICU italiane partecipanti alla ricerca era del 45%.
Secondo studi recenti, inoltre, l’incidenza della condizione è in
aumento per effetto dell’invecchiamento della popolazione e
della conseguente maggior comorbidità, del crescente numero
di pazienti infettati da microrganismi resistenti al trattamento,
dell’aumento del numero di pazienti immunocompromessi o
che subiscono interventi chirurgici ad alto rischio.
•
Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units : Results of the
SOAP study.
Crit Care Med 2006;34:344353.
SEPSI: Fattori di rischio
• Fattori epidemiologici: aumento dell’età media e delle
patologie associate ad un maggior rischio di infezioni
(neoplasie, AIDS, interventi chirurgici, malattie
croniche)
• Fattori iatrogeni: diffuso uso di mezzi invasivi (cateteri
venosi centrali, ventilazione meccanica), antibiotici a
largo spettro e corticosteroidi
• Fattori ambientali: mancanza di barriere fisiche tra i pz
e inosservanza delle norme igieniche
Diagnosi microbiologica
Emocolture: strumento essenziale per la diagnosi di sepsi.
Emocolture realmente positive costituiscono il miglior
criterio per la definizione di sepsi e della sua causa.
Purtroppo in un rilevante numero di pazienti con sepsi le
emocolture sono negative, molti fattori ostacolano la resa
diagnostica delle emocolture:
Volume prelievo di sangue.
Numero delle emocultere.
Tempo di raccolta prelievi.
Durata incubazione flaconi.
Contesto clinico.
EMOCOLTURE: QUANDO ESEGUIRLE?
 Febbre (> 38°C)
 Ipotermia (< 36°C)
 Leucocitosi(> 10.000/μl)
 Granulocitopenia(< 1.000/μl)
 Ipotensione
 Infezioni , sospette o comprovate (meningiti,
polmoniti, endocarditi, ascessi, SSTIs, etc..)
 Insufficienza renale
 Alterato stato mentale
 Pazienti immunoconpromessi
CUMITECH Blood Cultures IV, ASM Press 2005
Mylotte and Tayara EJCMID 2000 Indications for Blood Cultures Indications Cultures
PRINCIPALI SITUAZIONI CLINICHE IN CUI È IMPORTANTE ESEGUIRE IL
TEST E % ATTESA DI POSITIVITÀ.







Endocarditi e infezioni endovascolari
Epiglottite acuta
Meningite batterica
Pielonefrite ascendente
Osteomielite ematogena
Polmonite batterica
Ascessi endoaddominali
 Febbre di natura non determinata
85-95 %
80-90 %
50-80 %
30-50 %
30-50 %
5-30 %
varia
varia
Estratto da:”TRACCIA PER LA FORMULAZIONE DI LINEE GUIDA PER
L’EMOCOLTURA” Elaborazione a cura di AMCLI (CoSBat) e APSI”
Health Protection Agency (2005). Investigation of blood cultures (for organisms other than
mycobacterium species). National Standard Method BSOP 37 Emissione 5.
Downloaded from http://cid.oxfordjournals.org/ at IDSA member on July 11, 2013
A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases:
2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the
American Society for Microbiology (ASM)a
Consensus guidelines and expert panels recommend peripheral
venipuncture as the preferred technique for obtaining blood for culture
based on data showing that blood obtained in this fashion is less likely
to be contaminated than blood obtained from an intravascular catheter
or other device. Several studies have documented that iodine tincture,
chlorine peroxide, and chlorhexidine gluconate (CHG) are superior to
povidone-iodine preparations as skin disinfectants for blood culture.
Iodine tincture and CHG require about 30 seconds to exert an antiseptic
effect compared with 1.5–2 minutes for povidone-iodine preparations.
CHG is NOT recommended for use in infants less than 2 months of age.
Clinical Infectious Diseases Advance Access published July 10, 2013
A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases:
2013 Recommendations by the Infectious Diseases Society of America (IDSA)
and the American Society for Microbiology (ASM)a
Clinical Infectious Diseases Advance Access published July 10, 2013
Washington, J. A. II 1975. Mayo Clin. Proc. 50:91–98.
Weinstein, M. P., et al. 1983. Rev. Infect. Dis. 5:35–53.
Cockerill, F. R., et al. 2004. Clin. Infect. Dis. 38:1724–1730.
Lee, A. S., et al. 2007. J. Clin. Microbiol. 45:3546–3548
SUSPECTED CATHETER SEPSIS
1. Draw two blood culture sets.
2. One set is obtained from the suspected catheter.
3. At the same time, a second set must be from a
separate peripheral site.
4. Time of collection should be noted for both specimens.
5. If the catheter is removed, a section of about 1 inch in length
from an intradermal portion is to be cut aseptically and sent to
Microbiology in a dry sterile container. Do not send catheter tip
without sending concomitant blood cultures. In such cases the
catheter tip will not be cultured.
Clinical Infectious Diseases Advance Access published July 10, 2013
Johns Hopkins Medical Microbiology Specimen Collection Guidelines – Updated 6/2013
ACUTE ENDOCARDITIS
1. Draw 2-3 culture sets from separate sites within 30
minutes of each other and before beginning
antimicrobial therapy.
2. Begin therapy after cultures are obtained.
SUBACUTE ENDOCARDITIS
1. Draw 2-3 blood culture sets on day 1, spaced 30-60 minutes
apart. This may help to document a continuous bacteremia.
2. If all are negative additional sets can be drawn on days 2 and 3
(no more than 4 sets in a 24 hour period).
3. Immediate antibiotics are less important than
establishing a specific microbial diagnosis.
C. I. D.: July 10, 2013
J. H. M. M.: Updated 6/2013
Blood cultures are the preferred sample for the
diagnosis of epiglottitis
Clinical Infectious Diseases Advance Access published July 10, 2013
LOWER RESPIRATORY TRACT INFECTIONS
Clinical Infectious Diseases Advance Access published July 10, 2013
Lacroix et al. Critical Care 2013, 17:R24
Results: We included 54 patients with HCAP. Pathogens were identified in 46.3% of cases using
mini-BAL and in 11.1% of cases using blood cultures (P <0.01). When the patient did not
receive antibiotic therapy before the procedure, pathogens were identified in 72.6% of cases
using mini-BAL and in 9.5% of cases using blood cultures (P <0.01). We noted multidrugresistant pathogens in 16% of cases. All bronchoscopic procedures could be performed in
patients without complications.
INTRA-ABDOMINAL INFECTIONS
Blood cultures are rarely positive in cases of PDAP
Clinical Infectious Diseases Advance Access published July 10, 2013
Clinical Infectious Diseases Advance Access published July 10, 2013
BONE AND JOINT INFECTIONS
Osteomyelitis may arise as a consequence of hematogenous seeding of
bone from a distant site, extension into bone from a contiguous soft tissue
infection, extension into bone from a biofilm on a contiguous prosthesis,
or direct traumatic inoculation.
Similarly, joint infections may develop by any of these routes, but occur
most often by hematogenous seeding.
From the perspective of pathophysiology, specific nature of infection and
to at least some extent, clinical course, it is useful to classify bone
infections based on pathogenesis.
With joint infections, a classification scheme based on specific site of
involvement and tempo of disease is most instructive; ie, acute versus
chronic arthritis and septic bursitis. With few exceptions, bone and joint
infections are usually monomicrobic. Rarely, such infections are
polymicrobic
Clinical Infectious Diseases Advance Access published July 10, 2013
BONE AND JOINT INFECTIONS
blood cultures collected during febrile episodes are
recommended for the evaluation of patients suspected
of having secondary bacteremia or fungemia.
Concomitant blood cultures are indicated for detection
of some systemic agents of osteomyelitis and joint
infections, but not for prosthetic joint infection.
Clinical Infectious Diseases Advance Access published July 10, 2013
GENITAL INFECTIONS
Clinical Infectious Diseases Advance Access published July 10, 2013
SKIN AND SOFT TISSUE INFECTIONS
Blood cultures should be collected for
detection of systemic disease secondary to the wound.
SKIN AND SOFT TISSUE INFECTIONS
Clinical Infectious Diseases Advance Access published July 10, 2013
SKIN AND SOFT TISSUE INFECTIONS
Clinical Infectious Diseases Advance Access published July 10, 2013
SKIN AND SOFT TISSUE INFECTIONS
Clinical Infectious Diseases Advance Access published July 10, 2013
Clinical Microbiology and Infection ª2012 European Society of Clinical Microbiology and
Infectious Diseases
WHAT ARE THE BEST TESTS FOR
DIAGNOSING CANDIDAEMIA?
Clinical Microbiology and Infection ª2012 European Society of Clinical Microbiology and
Infectious Diseases, CMI, 18 (Suppl. 7), 9–18
TABLE 2. Summary of recommendations by Candida disease, specimen and test
evaluated
Disease
Specimen
Test
Recommendation
Candidaemia
Invasive candidiasis
Chronic
disseminated
candidiasis
Blood
Blood culture
Essential investigation
Serum
Mannan/anti-mannan
B-D-glucan
Recommended
Recommended
Blood
Blood culture
Essential investigation
Serum
Mannan/anti-mannan
B-D-glucan
Recommended
Recommended
Blood
Blood culture
Essential investigation
Serum
Mannan/anti-mannan
B-D-glucan
Recommended
Recommended
Essential investigation means it must be done if possible.
Recommended Technique is accurate in 50–70% of cases (reasonable number)
BLOOD CULTURES (BC) ARE ESSENTIAL FOR
DIAGNOSING CANDIDAEMIA
The number of BC recommended in a single session is 3 set
with a total volume varying according to the age of the patient:
40–60 mL for adults,
2–4 mL for children under 2 kg,
6 mL between 2 and 12 kg, and
20 mL between 12 and 36 kg.
The timing for obtaining the BC is one right after the other from
different sites, and venipuncture remains the technique of choice.
A BC set comprises of 60 mL blood for adults obtained in a single
session within a 30-min period and divided in 10-mL aliquots among
three aerobic and three anaerobic bottles.
The frequency recommended is daily when candidaemia is suspected,
and the incubation period must be at least 5 days.
Clinical Microbiology and Infection ª2012 ESCMID
Lippincott's Illustrated Reviews: Microbiology
(Lippincott's Illustrated Reviews Series). 2007
Microbiological Findings and BSIs • CID 2009:48 (Suppl 4) • S239
ULCERA DA PRESSIONE
Viene definita ulcera da pressione, una lesione a livello tissutale
causata da prolungata pressione e/o ripetuta frizione tra il piano
d’appoggio e la superficie ossea di un soggetto immobilizzato per
età avanzata e/o grave compromissione della funzionalità
neuromotoria. Il fenomeno interessa la cute, il derma e gli strati
sottocutanei, fino a coinvolgere, nei casi più gravi, la muscolatura
e le ossa. La compressione tissutale, indicata come principale
fattore patogenetico, diventa lesiva quando supera la soglia dei 32
mmHg che rappresenta appunto il valore pressorio normale della
circolazione capillare arteriosa. Lo stress meccanico e la
concomitante riduzione della circolazione ematica locale, con
conseguente ischemia e ipossia sono alla base dell’evoluzione
necrotica delle ulcere.
Donelli, et al Istituto Superiore di Sanità 2005, iii, 23 p. Rapporti ISTISAN 05/41
Le ulcere da pressione possono essere classificate secondo criteri clinici, topografici, e di stato.
Nell’ambito dei criteri clinici l’European Pressure Ulcer Advisory Panel (EPUAP) e l’Agency for Health Care
Policy and Research (AHCPR) forniscono indicazioni universalmente accettate che permettono di
classificare le ulcere da pressione in quattro distinti stadi clinici ai quali l’NPUAP (National Pressure Ulcer
Advisory Panel) ha aggiunto, per gli USA, due ulteriori stadi riguardanti il sospetto danno degli strati
tissutali profondi e le lesioni non stadiabili
R. Bernabei, et al: G Gerontol 2011;59:237-243
R. Bernabei, et al: G Gerontol 2011;59:237-243
SERVIZIO SANITARIO REGIONALE
EMILIA-ROMAGNA
Azienda Ospedaliero – Universitaria di Ferrara
Altri dati epidemiologici emersi dallo studio
Sedi interessate
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



Sacro
Occipite
Trocantere
Ischio
Malleolo
Tallone
Altro
41,3%
1,4%
5,4%
2,7%
3,1%
35,9%
10,2%
febbraio 2013
EMOCOLTURE
2° QUESTIONARIO SU ALCUNI ASPETTI RELATIVI ALLA APPLICAZIONE DELLA
APPROPRIATEZZA PRESCRITTIVA, DI REFERTAZIONE e ORGANIZZATIVA
struttura tipologia
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
MV
BM
MV
BM
BM
BM
BM
BM
BM
BM
BM
MV
BM
BM
BM
BM
LG
LG
Prelievo Clinica
1
0
1
1
0
1
1
0
0
1
1
0
0
0
0
1
0
1
1
0
0
1
0
0
0
1
0
0
0
0
P.S.
EMATOL.
DIALISI
TERAPIA
INTENSIVA
CAMERA
OPERAT.
T.I.
NEONAT.
1
1
1
0
1
1
0
1
0
0
1
0
0
1
1
1
0
0
1
0
1
0
0
0
1
0
1
0
0
0
0
1
0
1
1
1
1
0
0
1
0
0
1
0
0
1
1
1
1
1
1
0
1
1
1
1
0
0
1
1
0
1
0
1
1
1
1
1
1
1
1
1
1
0
1
1
0
1
1
1
1
0
1
0
1
0
0
0
0
0
1
0
0
0
0
1
LG Prelievo: linee guida concordate per le tecniche di prelievo delle Emocolture: asepsi, volume appropriato, etc.
LG Clinica: protocolli concordati e condivisi delle Emocolture in base al sospetto diagnostico: numero e ritmo dei prelievi.
1 ; 0: Rispettivamente presenza, assenza.
Ringraziamenti
Ai colleghi dei Laboratori contattati che, compilando
e restituendo il questionario, hanno reso possibile
l’indagine.
Un sentito ringraziamento ai colleghi del Gruppo di Lavoro
AdAMeL:
Dott.ssa Marina Vitillo (ACO S. Filippo Neri)
Dott.ssa Maria Teresa Muratore (Osp. Belcolle VT-Del. Lazio SIBioC)
Dott.ssa Fiorella Bottan (AO S. Giovanni Addolorata)
Dott.ssa Alessandra Amendola (INMI Spallanzani)
Dott. Francesco Bondanini (Osp. S. Pertini)
Dott. M. Daniele Naim (Pol. Di Liegro)
Prof. MaurizioMuraca (Osp. Ped. Bambino Gesù)
Dott. Sebastiano La Rocca (ACO S. Filippo Neri)
Ringrazio per i dati forniti la Dott.ssa Gabriella Parisi
U.O.C Lab. Micr. e Virol. S. Camillo-Forlanini. Sez. Emocolture