La diagnosi microbiologica delle infezioni batterichenel2019 · Fondazione Policlinico...
Transcript of La diagnosi microbiologica delle infezioni batterichenel2019 · Fondazione Policlinico...
La diagnosi microbiologica delle infezioni batteriche nel 2019
Teresa Spanu
Fondazione Policlinico Universitario A. Gemelli, IRCSSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Microbiological diagnostic stewardship “coordinated guidance and interventions to improve appropriate use of microbiological
diagnostics to guide therapeutic decisions. It should promote appropriate, timely diagnostic testing, including specimen
collection, and pathogen identification and accurate, timely reporting of results to guide patient treatment
Clinical bacteriology is a discipline that focuses on rapidly characterizing pathogen samples to
direct the management of individual infected patients (diagnostic microbiology) and to
monitor the epidemiology of infectious disease (public health microbiology)
HOT TOPIC/ Diagnosis of bacterial infections
Time toresults
3
• Non lab time• Ordering time
• Collection time
Significant delays between collection of samples and lab results. Delays can occur both at the patient's bedside and in the laboratory
To the lab AS SOON AS POSSIBLE for entry in the blood culture system
• Trasportation time
• Lab time: hours of opening
The median time from blood culture collection to growth detection was reduced by 10.1 h in the Bactec ON arm
(12/7 vs 24/7)
Murray PR, Masur H. Crit Care Med. 2012 Dec;40(12):3277-82.
•Time to growth
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCSSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Banerjee et al . Clin Infect Dis. 2016 15;63:1332-1339
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
P Morency-Potvin et al. CMR 2016
.
Blue arrows represent the conventional microbiology pathway, orange arrows represent the RDT pathway, and green arrows represent opportunities for the laboratory and antimicrobial stewardship teams to improve communication of results. AST, antimicrobial susceptibility testing.
There are a number of changes underway in modern clinical microbiology laboratories
SIR - new definitions 2019
Susceptible
Normal exposureNormal
exposureIncreasedexposureIncreasedexposure
Resistant
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Gunnar Kahlmeter and the EUCAST Steering Committee
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
HE = High exposure for agent (see table of dosages, last tab in breakpoint table)
HE= high exposure
Pseudomonas spp.
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HE= high exposure
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
All clinical breakpoints are related to the achievable level of exposure* of the microorganism.
The achievable level of exposure* depends on many factors. Individual differences in pharmacokinetics are allowed for in the calculations leading up to pharmacodynamic indices following population simulation. Others factors as follows are determined by the the site of infection or can be varied during therapy:
1. Site of infection – concentration in certain tissues and body fluids may be high (urine, bile, lymphatic
tissues).2. Dose and dosing frequency3. Mode of administration (Oral, Intravenous, IV infusion etc)
*Exposure is a function of how the mode of administration, dose, dosing interval, infusion time, as well as distribution,
metabolism and excretion of the antimicrobial agent will influence the infecting organism at the site of infection.
Gunnar Kahlmeter and the EUCAST Steering Committee
Acceleration of identification of positive blood cultures by MALDI-TOF MS
Short term incubation cultures: The incubation time needed to achieve species-level identification was 5.9 and 2.0 h for Gram-positive aerobic cocci (GPC, n = 86) and Gram-negative aerobic rods (GNR, n = 42), respectively. Idelevich EA. CMI. 2014 Apr 3.
Detection of microbial growth
Lab resultsPLoS One.2009; 4:e8041S
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Bruker's MALDI Biotyper ; Vitek MS Funke DJ, Kumar A. Critical Care Clinics 2011 27: 53-76; May 2011 Clinical Laboratory News: Bloodstream Pathogens Fournier et al. Nat Rev Microbiol. 2013; 11:574-585Bauer et al. Clin Infect Dis. 2014.59 : S134Advice E, Carroll KC. Infect Dis Clin North Am. 2014 Jun;28(2):215-35 Clinical Infectious Diseases 2009; 49:543–51 AST, antimicrobial susceptibility testing; MALDI-TOF MS, matrix-assisted laser desorption ionization time-of-flight mass spectrometry
HOT TOPIC/ Diagnosis of bacterial infections
Rapid AST directly from blood culture bottlesEUCAST has published recommendations for short incubation (4, 6 and 8 hours) AST directly from positive blood culture bottles:
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Riedel and Carroll, 2016 Clin Chest Med
Acceleration of identification of positive blood cultures by molecular methods
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Ramanan et al. CMR 2018Riedel and Carroll, 2016 Clin Chest Med
Although multiplex assays have potential benefits over routine testing by reducing turnaround time, there are certain disadvantages to consider. These tests do not overcome the technical and sensitivity issues of blood cultures (BCs), detect only a limited spectrum of microorganisms, may not be capable of identifying all pathogens in mixed infections, even if the organisms are included in the panel and are largely “add-on” tests. False-positive results may also occur. To realize maximal benefits, these assays should be performed 24 h a day/7 days a week, adding logistical hurdles for both the laboratory and the stewardship system
BSI, bloodstream infection
HOT TOPIC/ Microbiological diagnosis of bacterial infections
Acceleration of identification of positive blood cultures by molecular methods
In order to enable the rapid escalation or deescalationof antimicrobial therapy, the results of these assays should be reported to providers as rapidly and directly as possible and should also ideally be communicated to an expert in antimicrobial stewardship who can work with the providers to optimize therapy
Studies evaluating the effects of panel-based molecular assays for detection of select microorganisms and resistance genes in positive blood culture bottles on clinical and economic outcomes for patients with bacteremia
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Ramanan et al. CMR 2017
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Opota et al . CMI 2015
Blood-culture (BC) independent nucleic acid methods for the microbial diagnosis of bacteremia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
BC-independent nucleic acid amplification-based detection of pathogen-associated molecular patterns applied on whole blood does not only circumvent the limiting BC step but also provides a much lower turnaround time
Banerjee et al. CID. 2016 15;63:1332-1339Opota et al . CMI 2015Riedel and Carroll, 2016 Clin Chest Med
BC-based nucleic acid methods
Blood-culture (BC) independent nucleic acid methods for the microbial diagnosis of bacteremia
1-2.5 h
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Mwaigwisya et al. 2015; Expert Rev. Mol. Diagn. 15(5), 681–69
Because of current limitations, these assays are used to complement blood culture rather than replace it
Blood-culture (BC) independent nucleic acid methods for the microbial diagnosis of bacteremia
HOT TOPIC/ Diagnosis of bacterial infections
CSF PCR demonstrates sensitivity of 87-100 % and specificity of 98-100%, respectively. It is especially useful if antibiotics have been given prior to lumbar puncture
ABM, acute bacterial meningitis; CSF, cerebrospinal fluid; PCR, polymerase chain reaction
Workflow pathways for diagnosing ABM: CSF PCR
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
ESCMID guidelines, 2016IDSA guidelines, 2004UK guidelines, 2016
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Multiplex respiratory panel
Ramanan et al. CMR 2017
Allplex
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√Legionella pneumophila
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√√
√
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Allplex
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Echaverria et al Journal of Clinical Virology 2018
Diagnostic yield was significantly higher by FilmArray-RP (81%) than by immunofluorescence assay (IFA; 31%)(p < 0.001)
Improved clinical sensitivity and range of pathogens detected by FilmArray™ compared to immunofluorescence assay
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Echaverria et al Journal of Clinical Virology 2018
Impact on Clinical Decision-making
R Patel. Mayo Clin Proc. 2016
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
FilmArray detected pathogens in 35.3% of specimens, compared to 6.0% for culture. Median time from collection to result was 18 hours for FilmArray and 47 hours for culture.
Cybulski et al. CID 2018
Improved clinical sensitivity and range of pathogens detected by FilmArray™ compared to traditional stool culture
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Patients with an infectious cause of acute gastroenteritis detected by FilmArray (B) were more likely (P = .0148) to receive targeted rather than empirical therapy when compared to those detected by culture (A)
Cybulski et al. CID 2018
Impact on Clinical Decision-making
(A) (B)
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Test ordering guidance for infectious diarrhea
R Patel. Mayo Clin Proc. 2016
aWarning signs and risk factors for severe disease include fever, bloody diarrhea, dysentery, severe abdominal pain, dehydration, hospitalization, and immunocompromised state. bGastrointestinal Pathogen Molecular Panels test for common bacterial, viral and parasitic causes of diarrhea.cSubmit 3 stool collected on separate days for maximum sensitivity.
Multiplex syndromic panels are more sensitive than conventional methods, although questions remain regarding clinical utility and cost effectiveness.
Blood cultures grew clinically significant bacteria for 12 out of the 75 patients (16%)
In comparison, 16S metagenomics detected clinically significant bacteria in 18 patients (24%), including 8 of the 12 blood culture positive patients and 10 patients with a negative blood culture. In total, 22 patients (29.3%) were classified as confirmed bBSI by blood culture and/or 16S metagenomics
bBSI, bacterial bloodstream infection
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Paisse et al. Transfusion 2016
Comprehensive description of blood microbiome from healthy donors assessed by 16S targeted metagenomic sequencing
Most of the blood bacterial DNA is located in the BC (93.74%), and RBCs contain more bacterial DNA (6.23%) than the plasma (0.03%). The distribution of 16S DNA is different for each fraction and spreads over a relatively broad range among donors. BC, buffy coatRBC, red blood cells
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Caliendo et al. Clin Infect Dis 2013;57:S139–5175Murdoch D R et al. JCM 2009; 47: 3405-08Banerjee et al . Clin Infect Dis. 2016 15;63:1332-1339
We engage an educational campaign to teach clinician teams appropriate indications for ordering, collection, transportation and placement of BC bottles
Guidance in the preanalytic stage at the Fondazione Policlinico UniversitarioA. Gemelli IRCCS
BC, blood culture
Check-in
Sample entry (24 X 7)
Transportation time
Collection time
Ordering time
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Menchinelli et al. Sumitted
HOT TOPIC/ Diagnosis of bacterial infections
Efficient Inactivation of Clinically Relevant Antimicrobial Drug Concentrations by BACT/ALERT® or BACTEC™ Resin-Containing Media in Simulated Adult Blood Cultures
At concentrations almostequivalent to the lowest possiblelevels of antibiotics in the plasma, both BACT/ALERT® and BACTECTM
Plus media were efficient against13 antibiotics, with the exceptionof meropenem (but only in combination with E. coli or K.
pneumoniae).
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Fiori B et al JCM 2016; Bruker's MALDI Biotyper ; Vitek MS Funke DJ, Kumar A. Critical Care Clinics 2011 27: 53-76; May 2011 Clinical Laboratory News: Bloodstream Pathogens Fournier et al. Nat Rev Microbiol. 2013; 11:574-585Bauer et al. Clin Infect Dis. 2014.59 : S134Advice E, Carroll KC. Infect Dis Clin North Am. 2014 Jun;28(2):215-35 Clinical Infectious Diseases 2009; 49:543–51AST, antimicrobial susceptibility testing; MALDI-TOF MS, matrix-assisted laser desorption ionization time-of-flight mass spectrometry
Detection of microbial growth
Acceleration of identification of positive blood culturesHOT TOPIC/ Diagnosis of bacterial infections
Rapid AST directly from blood culture bottles
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Lab results
Workflow for rapid identification of BSIs at the clinical microbiology laboratoryof Fondazione Policlinico Universitario Gemelli
FilmArray BCID
Detection of microbial growth
MRSA POSITIVE
Parameter Result
A1 S.aureus positive
A2 mecA positive
A3 mecC negative
A4 S.epidermidis negative
A5 Sample control valid
A6 Inhibition control valid
A7
A8
Detection of resistance genes
Infectious diseaseconsultant AST
Lab results
MALDI-TOF MS
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
BSI, bloodstream infection; AST, antimicrobial susceptibility testing; MALDI-TOF MS, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, BC, blood cultureGenes detected: mecA, mecC, CTX-M-1, CTX-M-9; KPC, VIM, NDM-1, OXA-48, OXA-23, OXA-181
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
The appropriateness of antibiotic treatments was assessed at the time of BC collection (empirical therapy) and after notification of the procedure (targeted therapy) or AST (definitive therapy) results
Appropriateness of antimicrobial treatments in subgroups defined by the infecting pathogen's resistance status
Abbreviations: BSI, bloodstream infections; none refers to strains not carrying carbapenemase, extended-spectrum and plasmid-mediated AmpC β-lactamase genes
Fiori et al. submitted
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Development of a multiplex PCR platform for rapid, culture-independent detection of bacteria, antibiotic resistance, and Candida in human blood samples
Liotti et al. submitted
The sensitivity and specificity were 86.6% and 97.0% among patients with positive BCs for the organisms targeted by the assay, or fulfilling criteria for infection. The mean times to positive or negative assay’s results were 5.3 ± 0.2 h and 5.1 ± 0.1 h, respectively.
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Results
Work-flow for diagnosis of ABM at the microbiology laboratory of Fondazione Policlinico Universitario Gemelli IRCCS
ABM, acute bacterial meningitis; ID, identification AST, antimicrobial susceptibility testing;
Culture-based method Microscopic examination Molecular methods
16SrRNA PCR
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Results for 48 patients with bacterial meningitis by method
Results of
Microscopic examination
Culture testing
Rapid molecular method
PCR and sequencing
L. monocytogenes 3 6 6 6
N. meningitidis 4 3 9 9
S. agalactiae 1 1 1 1
S. pneumoniae 15 14 20 20
E. coli 2 3 3 3
C. koseri 1 1 0 1
F. nucleatum 1 0 0 1
E. cloacae 0 1 0 1
S.marcescens 0 1 0 1
S. pyogenes 2 2 0 2
Total 29 32 39 45
From 117 samples, bacterial DNA was detected in 45 (38.5%) and virus in 14 (12%). The rapid molecular method detected 1 pathogen in 39 (33.3%) specimens, compared to 32 (27.3%) detected by culture and to 29 (24.7) by microscopic examination
Multiplex respiratory panel
Ramanan et al. CMR 2017
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HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Microbial pathogens identified in 63 samples collected from 67 patients with pneumonia
Sample result Bacteria MoldsBacteria+
moldsBacteria+
virus
Bacteria+ molds+ virus
Virus
Positive 441 22 1 9 23 5
1 Mycobacterium tuberculosis (1)2 Pneumocystis jirovecii(1)3 Pneumocystis jirovecii (1)
A total of 82 microorganisms were detected in 54 samples. Of those, 79 (9%) weredetected by FilmArray pneumonia and 64 (81.4%) by the culture based method.
Additional resultsby Culture
Additional results by FilmArray
Concordantresults
Acinetobacter baumannii 0 1 9Aspergillus fumigatus* 2 0 0Escherichia coli 0 1 7Haemophilus influenzae 0 6 9Klebsiella aerogenes 0 0 2Klebsiella pneumoniae 0 0 2Legionella pneumophila 1 0 3Moraxella catharralis 0 1 4Mycoplasma pneumoniae 0 1 0Pseudomonas aeruginosa 0 2 6Staphylococcus aureus 0 3 13Streptococus pneumoniae 0 3 5Streptococus pyogenes 0 0 1Total 3 18 61
Results of the clinical evaluation of Film Array Pneumonia panel HOT TOPIC/ Diagnosis of bacterial infections
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
*Species not detectable by the FilmArray pneumonia panel
Fondazione Policlinico Universitario A. Gemelli, IRCCSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
Antibiogram data
Clinical microbiology laboratories also contribute to the success of stewardship programs through compilation of aggregate antimicrobial susceptibility data
Batteri Gram Negativi N° isolati
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Acinetobacter baumanni 5 R R 0% 0% 0% 0% 0% 100%
Citrobacter freundii 0
Enterobacter aerogenes 1 R R 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Enterobacter cloacae 2 R R 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Escherichia coli 3 33% 100% 100% 100% 100% 100% 100% 100% 100% 67% 67% 100% 100%
Klebsiella pneumoniae 4 R 100% 100% 75% 75% 75% 100% 100% 100% 100% 100% 75% 75% 100%
Morganella morganii 1 R R 100% 0% 0% 0% 100% 100% 100% 0% 0% 0% R R
Proteus mirabilis 2 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% 100% R R
Pseudomonas aeruginosa 2 R R 0% 0% 0% R 100% 100% 100% 100% 100% R R
Serratia marcescens 7 R R 100% 100% 100% 100% 100% 100% 100% R 71% 100% 100% R
Stenotrophomonas maltophilia 0
>=90% Sensibili
70-89 % Sensibili
< 70% Sensibili
Intrinsecamente resistenti
Antibiogramma cumulativo-Materiali Invasivi
Periodo 01/01/2016 - 30/09/2018
Percentuali di sensibilità
HOT TOPIC/ Diagnosis of bacterial infections
• Molecular methods based on seeking specific targets for pathogen identification and resistance genes are likely to be phased out in the coming years and replaced by more comprehensive methods, such as MALDI-TOF MS and genomic sequences method.
• These techniques are expected to contribute substantially to improving the etiological diagnosis and precision medicine.
• The tremendous promise of these new methods will require the successful development of clinical microbiologists capable of interpreting and evaluating microbiological data and placing these data in the appropriate clinical context.
• Appropriate budgets are need to make available these activities.
Concluding remarks
MALDI-TOF MS, matrix-assisted laser desorption ionization time-of-flight mass spectrometry
Fondazione Policlinico Universitario A. Gemelli, IRCSSUniversità Cattolica del Sacro CuoreIstituto di Microbiologia
HOT TOPIC/ Diagnosis of bacterial infections