Colistin-induced acute kidney damage | IDR


Sepsis and septic shock attributable to multidrug-resistant (MDR) gram-negative micro organism (GNB) are rising epidemics liable for elevated morbidity and mortality worldwide.1 The dearth of efficient antimicrobial brokers towards sure resistant GNB, equivalent to Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae, requires using colistin as a last-line resort.2 Colistin is a bactericidal antibiotic that disrupts the membrane integrity of GNB and reveals exercise towards MDR-GNB, however with an elevated threat of dose-dependent unwanted side effects, equivalent to nephrotoxicity and neurotoxicity.3 Colistin is a prodrug that requires additional metabolism to be transformed into its lively metabolite and requires a loading dose (LD) to succeed in the required therapeutic plasma focus. Pressing administration of an efficient antibiotic routine is an important first step in managing sepsis and septic shock, ideally throughout the first hour of analysis.4 In response to the current consensus pointers, an acceptable LD of colistin base exercise (CBA) infused at 0.5–1 h is really helpful, with the administration of the primary upkeep dose (MD) based mostly on the affected person’s renal perform after 12–24 h.5

Pharmacokinetic research of colistin confirmed a sluggish conversion fee of the inactive drug colistimethate sodium to the lively drug colistin, which can take as much as 3 days with out an LD to attain therapeutic drug focus given its lengthy half-life.6 The administration of an LD in intensive care items (ICUs) is difficult contemplating the comorbidities and concomitant drugs that would enhance the chance of growing critical unwanted side effects as a result of colistin administration.5,6

The affect of utilizing colistin LD for scientific remedy in ICU sufferers was evaluated in 4 observational research with a comparatively small pattern measurement. Within the first examine (25 sufferers with sepsis), scientific remedy and bacteriological clearance had been achieved in 82.1% and 73.9% of the sufferers, respectively, with a reported incidence of acute kidney damage (AKI) of 17.8%.7 The second examine (70 sufferers with extreme sepsis and septic shock) reported scientific decision in 77% of the sufferers, with an AKI incidence of 44%.8 Neither of those two research concerned a comparator group. The third examine (46 sufferers with an preliminary LD and 46 sufferers with out an LD) had varied an infection websites and reported scientific remedy in 63% of the sufferers within the LD group and in 41.3% of the sufferers with out an LD (p=0.04).9 AKI occurred in 32.2% and 26% of the sufferers within the LD and comparator teams, respectively (p=0.64). The fourth examine evaluated MDR-GNB pneumonia (30 sufferers with an preliminary LD and 42 sufferers with out a LD) and reported a scientific remedy in 55% of the sufferers belonging to the LD group and in 67% of the sufferers within the comparator group (p=0.31).10 The LD group skilled extra AKI than the comparator group (58% vs 50%, p=0.59). The latter two research point out contradictory outcomes relating to using colistin LD for scientific remedy, with an settlement on the upper incidence of AKI within the LD group. Nonetheless, these outcomes weren’t statistically important.

On this examine, we aimed to analyze the speed of scientific failure together with the incidence of AKI following the administration of colistin LD vs no LD in critically ailing sufferers with sepsis or septic shock.


Research Design and Individuals

This was a single-center retrospective cohort examine. Grownup ICU sufferers with suspected or confirmed gram-negative infections admitted between Might 1, 2016, and December 31, 2020, had been included within the examine. All sufferers had been administered at the least two doses of intravenous colistin throughout their ICU admission to any of the ten ICUs within the Nationwide Guard Well being Affairs (NGHA) central area establishments. The institutional evaluation board (IRB) approval for this examine was granted by the King Abdullah Worldwide Medical Analysis Middle (KAIMRC) (examine quantity NRC21R/071/03). Affected person consent kind was waived by the ethics committee as a part of the IRB approval, based mostly on the retrospective nature of the examine to abides by the Declaration of Helsinki Legislation. Sufferers had been included within the examine in the event that they had been critically ailing, aged ≥18 years, and recognized with sepsis based mostly on the Worldwide Classification of Ailments, Tenth Revision (ICD-10) codes. Sufferers who used colistin empirically for suspected or confirmed gram-negative infections had been included. After screening, affected person ought to have acquired a loading dose per the discretion of clinician within the loading dose group. Upkeep dosing of colistin was counted from the primary dose if the treating clinician didn’t doc the aim of this dosing. Pregnant sufferers had been excluded from the examine. Occasions had been documented in the event that they occurred through the ICU keep till ICU discharge after enchancment or in-hospital mortality, whichever occurred first.


This examine was carried out within the grownup medical, surgical, trauma, and burn ICUs at KAMC, a tertiary-care educational referral NGHA hospital in Riyadh, Saudi Arabia. The ICU admits critically ailing sufferers and operates as closed items with a 71-ICU mattress capability with 24/7 onsite protection by crucial care board-certified intensivists.

Knowledge Assortment

On this examine we included demographic and scientific knowledge equivalent to age, intercourse, weight, and weight problems, based mostly on a physique mass index of >35 kg/m2. Knowledge assortment for baseline traits included, however was not restricted to, the supply of an infection, baseline temperature, lactic acid upon analysis, baseline serum creatinine, and cumulative fluid steadiness inside 72 h of ICU admission. Moreover, the vasoactive-inotropic rating, acute physiology and continual well being analysis (APACHE II) rating, and sequential organ failure evaluation rating had been assessed. Comorbidities previous to ICU admission together with hypertension, coronary heart failure, diabetes mellitus, continual kidney illness, dialysis, and AKI previous to colistin administration, based mostly on chart documentation had been included. Moreover, mechanical air flow, resistant patterns (if out there), and co-administration of nephrotoxic drugs, together with aminoglycosides, vancomycin, beta-lactams, and loop diuretics, had been considered. Inhaled colistin and intravenous colistin LD and MD in milligram per kilogram and length of intravenous remedy (days) had been reviewed and recorded from our digital medical data. After screening, affected person’s who had been stratified to the LD group ought to have acquired a documented loading dose per the discretion of clinician within the notes apart from the digital order. Upkeep dosing of colistin was counted from the primary dose if the treating clinician didn’t doc the aim of this dosing within the charts. Modifications in MD was adopted in case of changes in renal perform and the analysis crew determined to make use of first dosing after LD as an MD for consistency.


This examine aimed to analyze the speed of scientific failure and AKI predictors in critically ailing septic sufferers when evaluating the intravenous LD of colistin with no LD administration.


The most important consequence was the speed of scientific failure between the 2 teams. Minor outcomes included mechanical air flow length, hospital and ICU size of keep (LOS), in-hospital mortality, and discharge practical standing. The times till which the sufferers had been afebrile, re-infection inside 3 days, colistin-induced nephrotoxicity, and neurotoxicity had been reported.


  • Sepsis was outlined utilizing the ICD-10 Scientific Modification code.11
  • Critically ailing affected person was outlined as any affected person who was admitted to the ICU.
  • Septic shock: Any supply of an infection, lactic acid >2 mmol/L, requiring vasopressors to take care of a systolic blood strain of >90 mmHg.
  • Scientific failure was outlined as persistence or worsening of the presenting indicators and signs or demise occurring inside 4 days of remedy.
  • AKI was outlined utilizing the AKI Community (AKIN) definition.12

Knowledge Administration and Statistical Evaluation

Descriptive statistics had been used to summarize the affected person demographics and scientific outcomes, with knowledge offered as medians (interquartile vary (Q1-Q3)] and frequencies (percentages), as acceptable. The Mann–Whitney U-test was used to check steady variables. Pearson’s chi-square take a look at was used to check the explicit variables. We estimated the unadjusted odds ratio (OR) of failure between the 2 teams and the related 95% confidence intervals (CIs) utilizing the Baptista–Pike methodology. Thereafter, we used a a number of logistic regression mannequin to calculate the OR of scientific failure (main consequence) after adjusting for coronary heart failure, continual kidney illness, hypertension, diabetes mellitus, septic shock, dialysis, mechanical air flow, pneumonia, intra-abdominal infections, urinary tract an infection, and bacteremia. Statistical significance was outlined as a two-sided p worth <0.05. Statistical analyses and knowledge graphing had been carried out utilizing Prism 9 model 9.2.0.


Of the 163 sufferers screened, 103 had been included on this examine. The baseline demographics are proven in Desk 1. In our examine, 83 (80.58%) sufferers had a documented analysis of septic shock upon colistin administration. Hypertension and diabetes mellitus had been the commonest comorbidities amongst 65 (63.11%) and 63 (61.17%) sufferers, respectively. Fifty-six sufferers (54.37%) acquired colistin LD. Nighty-one (88.35%) sufferers in our examine had at the least one extra nephrotoxic medicine co-administered with colistin. Of these nephrotoxic drugs, carbapenems and vancomycin had been essentially the most administered amongst 80 (87.91%) and 71 (78.02%) sufferers, respectively. The median colistin LD administered to the sufferers in our examine was 160 mg CBA (roughly 2 million IU colistimethate sodium equal) and the median upkeep dose was 85 mg CBA (roughly 1 million IU colistimethate sodium equal) twice every day. Intravenous colistin median remedy length in our inhabitants was 4 days.

Desk 1 Baseline Demographics

Main End result

A abstract of the foremost and minor outcomes of sufferers who underwent LD and no LD is proven in Desk 2. Eighty (77.67%) sufferers in our examine skilled scientific failure throughout their listed hospitalization based mostly on our definition of scientific failure. Amongst these sufferers, 47 (58.75%) acquired an LD (Desk 2). Nonetheless, scientific failure was not statistically important (OR 2.21, 95% CI 0.89–5.4, p=0.09).

Desk 2 Minor Outcomes

Based mostly on our a number of logistic regression mannequin, sufferers with septic shock (OR 5.851, 95% CI, 1.610–23.3; p=0.0086) and people receiving dialysis (OR 3.410, 95% CI, 1.085–11.6; p=0.0398) had a better incidence of scientific failure, as proven in Determine 1. Co-administration of carbapenems and development to septic shock had been related to elevated odds of inducing AKI, whereas vancomycin co-administration was related to decrease odds of inducing AKI, as proven in Determine 2.

Determine 1 Forest plot for a number of logistic regression of scientific failure prediction.

Determine 2 Predictor for acute kidney damage in septic sufferers utilizing intravenous colistin.

Minor Outcomes

No distinction was noticed in any of the secondary outcomes between the 2 teams. Fourteen (13.59%) sufferers developed AKI throughout colistin remedy, of which eight (57.14%) acquired an LD. The administration of colistin LD didn’t have an effect on the incidence of AKI (OR 1.08, 95% CI 0.42–2.74, p=0.86). The likelihood of admission to the ICU for ≤7 days was not considerably decrease amongst sufferers who acquired an LD (OR 0.78, 95% CI 0.3–1.89, p=0.6). The median ICU LOS was 11.5 days and 15.5 days amongst sufferers who acquired an LD compared to those that didn’t. This distinction was not statistically important (p=0.56).

In our examine, the mortality fee was 81.55% (84 sufferers). Of those sufferers, 46 (54.76%) underwent LD. Curiously, LD administration had no affect on mortality (OR 1.09, 95% CI 0.42–2.74, p=0.87). Among the many remaining 19 (18.44%) sufferers who had been discharged after hospitalization, 17 (89.47%) died. Of those, 9 (52.94%) acquired an LD. One (5.26%) affected person from every group was discharged to a rehabilitation or dialysis middle. The distinction between the teams by way of the vacation spot of sufferers’ discharge upon completion of their hospital course was not statistically important (p=0.98).


In our retrospective examine, we in contrast the efficacy and security of utilizing colistin LD versus no LD in critically ailing sufferers with sepsis or septic shock. Sufferers who underwent LD confirmed no variations in scientific and security outcomes. This may be attributed to the low median LD utilized in our establishment. The median colistin LD administered to the sufferers in our examine was 160 mg CBA (4.8 million IU colistimethate sodium equal), which is decrease than the really helpful LD by the 2019 worldwide consensus pointers.5

Colistin remedy comprising an LD in critically ailing sufferers was correlated with variable charges of scientific remedy from 50% to 82%.7–13 Nonetheless, the loading dose used within the beforehand talked about research was greater (300 mg CBA) than that utilized in our examine. Research which have in contrast the scientific outcomes between an LD and an ordinary dosing routine of colistin in critically ailing sufferers have proven conflicting outcomes. In a retrospective examine of 92 sufferers with MDR-GNB who acquired colistin for >24 h, an LD of 9 MIU (equal to 300 mg CBA) was related to a considerably greater remedy fee, outlined as each scientific and microbiological decision, in contrast with an ordinary dose of 6 MIU (200 mg CBA), 63% vs 41.3% (p=0.04), with no important enhance in AKI (32.2% vs 26%; p=0.64) or mortality (23% vs 27.5%; p=0.6).9 A earlier examine of 127 sufferers additionally demonstrated the achievement of each scientific and microbiological remedy with a excessive dose of colistin (>4.4 mg/kg/day, roughly 300 mg CBA per day for a super physique weight of 70 kg) in contrast with the usual dose on day 7 of remedy. Nonetheless, solely 15.7% of the sufferers acquired an LD. Excessive-dose colistin was the one unbiased predictor of remedy fee (OR 3.40, 95% CI 1.37–8.45, p=0.008).14 It’s value mentioning that each research reported colistin minimal inhibitory concentrations (MICs) of ≤2 mcg/mL.9,14 Nonetheless, the MIC was not reported in our examine, which can restrict our capability to have a correct comparability.

Two research have proven important enchancment in microbiological however not scientific response with LD administration.15,16 The primary examine was a potential cohort evaluating the effectiveness of 300 mg CBA LD (n=174) with no loading dose (n=81) in MDR Acinetobacter baumannii an infection.16 Solely microbiological response was greater with LD administration (87.9% vs 70.4%; p=0.0006). Scientific response and mortality had been related between sufferers with and with out LD (65.5% vs 70.4%; p=0.442) and (33.3% vs 3.1%; p=0.854). Though a lot of the included sufferers had comorbidities (80.3%), sufferers present process renal alternative remedy had been excluded, and solely 54% of sufferers had been admitted to the ICU within the LD group, with a imply APACHE II rating of 14.13. Not like our examine, during which the median APACHE II rating was 26 and 85.7% of sufferers had septic shock, dialysis and septic shock had been predictors of scientific failure (OR 3.410, 95% CI 1.085–11.6, p=0.0398) and (OR 5.851, 95% CI 1.610–23.3, p=0.0086), respectively. As well as, colistin MIC was very low (0.64–1 mcg/mL); nevertheless, this was not documented in our examine. These elements may clarify the excessive fee of scientific failure and mortality in our examine (77.67% and 81.55%, respectively). The second examine evaluated the connection between goal colistin focus and remedy outcomes in a retrospective cohort of 153 critically ailing sufferers with MDR organisms and located no important affiliation.16 There was no distinction between the scientific remedy (n=43) and scientific failure group (n=80) by way of LD administration (scientific remedy 60% vs scientific failure 42%; p=0.057); nevertheless, it was extra prone to end in microbiological eradication in those that acquired an LD (OR 2.783, 95% CI 1.126–6.880, p=0.027).16 These findings had been additional supported by a current meta-analysis of eight observational research that used high-dose colistin. Administration of an LD was related to a better fee of microbiological response (threat ratio [RR] 1.23, 95% CI 1.10–1.39), however not scientific response (RR 1.04, 95% CI 0.87–1.24).9 The excessive fee of scientific failure and mortality in our examine no matter LD administration could possibly be as a result of inherent traits of our affected person inhabitants and the severity of sickness, as evidenced by the excessive proportion of sufferers with septic shock, excessive APACHE II rating, vasopressor use, and comorbidities, together with dialysis, which had been excluded in lots of research.8,13,15–17

Some sufferers in our examine developed AKI (13.5%), which was not related to LD administration. Though the incidence of nephrotoxicity reported in earlier research was greater, based mostly on the AKIN standards,7–9,17 there was no important distinction between sufferers receiving a colistin LD and people receiving an ordinary routine9,16,18 (LD 58% vs normal dose 50%, p=0.59).9

A excessive mortality fee was noticed in our examine even in sufferers receiving an LD (OR 1.09, 95% CI 0.42–2.74, p=0.8). In a retrospective examine of 258 sufferers, a better colistin dose was related to improved survival; mortality was 38.6% with doses of three MIU of colistin, 27.8% with 6 MIU of colistin, and 21.7% with 9 MIU of colistin (p=0.009).11 Nonetheless, it has not been proven to have an effect on 28 days mortality in different research.9,10,14,15

Though colistin is necessary as a salvage remedy for a lot of MDR-GNBs, rising brokers are promising, secure, and efficient. Therapy of carbapenem-resistant Enterobacteriaceae with ceftazidime-avibactam was related to improved scientific outcomes and decreased 30 days mortality when used initially in contrast with colistin or alone.18–20 Equally, meropenem-vaborbactam was proven to be a secure and efficient various in chosen sufferers, and ceftolozane-tazobactam was proven to be secure and efficient for MDR P. aeruginosa.21–23

Our examine was restricted by its retrospective design and the small variety of sufferers. As well as, LD was comparatively decrease than the doses really helpful by current pointers.5 Scientific failure as a result of low publicity to colistin or greater MIC couldn’t be excluded as a result of plasma colistin focus and MIC of remoted organisms weren’t out there. The dearth of institutional pointers for colistin dosing could have affected the variability in dosing, which can be an added limitation. Nonetheless, our pattern measurement on this examine was comparatively bigger than the not too long ago printed knowledge for sufferers with sepsis and septic shock.8–13

In conclusion, in our retrospective examine relating to using colistin in critically ailing sufferers, LD administration was not related to the scientific failure fee or mortality discount. Predictors of colistin-induced AKI could embrace development of septic shock and carbapenem co-administration. Optimization of colistin dose is required via the implementation of institutional pointers to attain a excessive fee of sufficient LD and enhance remedy outcomes. Additional research are wanted to verify these findings.

Ethics Approval

IRB approval for this examine was granted by IRB of KAIMRC with examine quantity NRC21R/071/03.


This analysis acquired no particular grant from any funding company within the public, business, or not-for-profit sectors.


This unique analysis was accepted to be offered on the Society of Essential Care Medication’s (SCCM) 2022 Essential Care Congress and the summary is presently printed in Essential Care Medication ( The authors report no conflicts of curiosity for this work.


1. Rudd KE, Johnson SC, Agesa KM, et al. World, regional, and nationwide sepsis incidence and mortality, 1990-2017: evaluation for the World Burden of Illness Research. Lancet. 2020;395(10219):200–211. doi:10.1016/S0140-6736(19)32989-7

2. Mae E-SA, Zhong LL, Shen C, Yang Y, Doi Y, Tian GB. Colistin and its position within the Period of antibiotic resistance: an prolonged evaluation (2000-2019). Emerg Microbes Infect. 2020;9(1):868–885. doi:10.1080/22221751.2020.1754133

3. Falagas ME, Kasiakou SK. Colistin: the revival of polymyxins for the administration of multidrug-resistant gram-negative bacterial infections. Clin Infect Dis. 2005;40(9):1333–1341. doi:10.1086/429323

4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis marketing campaign: worldwide pointers for administration of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–377. doi:10.1007/s00134-017-4683-6

5. Tsuji BT, Pogue JM, Zavascki AP, et al. Worldwide consensus pointers for the optimum use of the polymyxins: endorsed by the American School of Scientific Pharmacy (ACCP), European Society of Scientific Microbiology and Infectious Ailments (ESCMID), Infectious Ailments Society of America (IDSA), Worldwide Society for Anti-infective Pharmacology (ISAP), Society of Essential Care Medication (SCCM), and Society of Infectious Ailments Pharmacists (SIDP). Pharmacotherapy. 2019;39(1):10–39. doi:10.1002/phar.2209

6. Nazer LH, Anabtawi N. Optimizing colistin dosing: is a loading dose crucial? Am J Well being Syst Pharm. 2017;74(1):e9–e16. doi:10.2146/ajhp150876

7. Dalfino L, Puntillo F, Mosca A, et al. Excessive-dose, extended-interval colistin administration in critically ailing sufferers: is that this the appropriate dosing technique? A preliminary examine. Clin Infect Dis. 2012;54(12):1720–1726. doi:10.1093/cid/cis286

8. Dalfino L, Puntillo F, Ondok MJ, et al. Colistin-associated acute kidney damage in severely ailing sufferers: a step towards a greater renal care? A potential cohort examine. Clin Infect Dis. 2015;61(12):1771–1777. doi:10.1093/cid/civ717

9. Trifi A, Abdellatif S, Daly F, et al. Efficacy and toxicity of high-dose colistin in multidrug-resistant Gram-negative bacilli infections: a comparative examine of a matched collection. Chemotherapy. 2016;61(4):190–196. doi:10.1159/000442786

10. Elefritz JL, Bauer KA, Jones C, Mangino JE, Porter Ok, Murphy CV. Efficacy and security of a colistin loading dose, high-dose upkeep routine in critically ailing sufferers with multidrug-resistant Gram-negative pneumonia. J Intensive Care Med. 2017;32(8):487–493. doi:10.1177/0885066616646551

11. ICD-10-CM Prognosis Code. Obtainable from: Accessed December 31, 2021.

12. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Harm Community: report of an initiative to enhance outcomes in acute kidney damage. Crit Care. 2007;11(2):R31. doi:10.1186/cc5713

13. Moni M, Sudhir AS, Dipu TS, et al. Scientific efficacy and pharmacokinetics of colistimethate sodium and colistin in critically ailing sufferers in an Indian hospital with excessive endemic charges of multidrug-resistant Gram-negative bacterial infections: a potential observational examine. Int J Infect Dis. 2020;100:497–506. doi:10.1016/j.ijid.2020.08.010

14. Gibson GA, Bauer SR, Neuner EA, Bass SN, Lam SW. Affect of colistin dose on international remedy in sufferers with bacteremia as a result of carbapenem-resistant Gram-negative bacilli. Antimicrob Brokers Chemother. 2016;60(1):431–436. doi:10.1128/AAC.01414-15

15. Katip W, Meechoui M, Thawornwittayakom P, Chinwong D, Oberdorfer P. Efficacy and security of excessive loading dose of colistin in multidrug-resistant Acinetobacter baumannii: a potential cohort examine. J Intensive Care Med. 2019;34(11–12):996–1002. doi:10.1177/0885066617725694

16. Jung S, Chung EK, Jun MS, Son ES, Rhie SJ. Variations in colistin administration and bacterial and remedy outcomes in critically ailing sufferers. Sci Rep:8781. Sci Rep. 2019;9(1):8781. doi:10.1038/s41598-019-44965-y

17. Bellos I, Pergialiotis V, Frountzas M, Kontzoglou Ok, Daskalakis G, Perrea DN. Efficacy and security of colistin loading dose: a meta-analysis. J Antimicrob Chemother. 2020;75(7):1689–1698. doi:10.1093/jac/dkaa064

18. Vardakas KZ, Rellos Ok, Triarides NA, Falagas ME. Colistin loading dose: analysis of the printed pharmacokinetic and scientific knowledge. Int J Antimicrob Brokers. 2016;48(5):475–484. doi:10.1016/j.ijantimicag.2016.08.009

19. Falagas ME, Rafailidis PI, Ioannidou E, et al. Colistin remedy for microbiologically documented multidrug-resistant Gram-negative bacterial infections: a retrospective cohort examine of 258 sufferers. Int J Antimicrob Brokers. 2010;35(2):194–199. doi:10.1016/j.ijantimicag.2009.10.005

20. Van Duin D, Lok JJ, Earley M, et al. Colistin versus ceftazidime-avibactam within the remedy of infections as a result of carbapenem-resistant Enterobacteriaceae. Clin Infect Dis. 2018;66(2):163–171. doi:10.1093/cid/cix783

21. Tumbarello M, Trecarichi EM, Corona A, et al. Efficacy of ceftazidime-avibactam salvage remedy in sufferers with infections attributable to Klebsiella pneumoniae carbapenemase-producing Ok pneumoniae. Clin Infect Dis. 2019;68(3):355–364. doi:10.1093/cid/ciy492

22. Wunderink RG, Giamarellos-Bourboulis EJ, Rahav G, et al. Impact and Security of meropenem-Vaborbactam versus Greatest-available Remedy in Sufferers with carbapenem-Resistant Enterobacteriaceae Infections: the TANGO II Randomized Scientific Trial. Infect Dis Ther. 2018;7(4):439–455. doi:10.1007/s40121-018-0214-1

23. Doi Y. Therapy choices for carbapenem-resistant Gram-negative bacterial infections. Clin Infect Dis. 2019;69(Suppl 7):S565–S575. doi:10.1093/cid/ciz830

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