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1.  Vaccination against human papillomavirus among 865 female students from the health professions in central Greece: a questionnaire-based cross-sectional study 
Background
There are still sparse data on vaccination coverage against human papillomavirus (HPV) among students in the health professions. The aim of this study was to investigate HPV vaccination coverage in female students from the health professions in Greece.
Methods
A self-administered, anonymous questionnaire was distributed to second-year and third-year female students pursuing degrees in medicine, nursing, and paramedical health disciplines in central Greece.
Results
Overall vaccination coverage was 44.3%. The major reason for lack of vaccination was fear about safety of the vaccine. Participants who had received information about safety of the vaccine from the mass media and paramedical students had lower vaccination coverage in comparison with students who had received information about vaccine safety from alternative sources.
Conclusion
Further quantitative and qualitative research is needed to design educational activities targeting female students in the health professions in order to create a positive domino effect and improve HPV vaccination coverage levels in Greece.
doi:10.2147/JMDH.S49558
PMCID: PMC3855014  PMID: 24324338
human papillomavirus; vaccination; coverage; students; health professions; mass media; Greece
2.  Seven-Year Surveillance of emm Types of Pediatric Group A Streptococcal Pharyngitis Isolates in Western Greece 
PLoS ONE  2013;8(8):e71558.
Background
An experimental 26-valent M protein Group A streptococcal (GAS) vaccine has entered clinical studies. Pharyngeal GAS emm type surveillances in different areas and time-periods enhance the understanding of the epidemiology of GAS pharyngitis. Moreover, these surveillances, combined with the data on GAS invasive disease, can play a significant role in the formulation of multivalent type-specific vaccines.
Methods
During a 7-year period (1999–2005), 2408 GAS isolates were recovered from consecutive children with pharyngitis in Western Greece. The overall macrolide resistance rate was 22.8%. Along the study period we noted a tendency towards significantly decreased rates of resistance, with the lowest rates occurring in 2002 (15.3%), 2003 (15%) and 2004 (16.7%). A random sample of isolates from each year, 338 (61.7%) of the 548 macrolide-resistant and 205 (11%) of the macrolide-susceptible, underwent molecular analysis, including emm typing.
Results
The 543 typed isolates had 28 different emm types. A statistically significant association was found between macrolide resistance and emm4, emm22 and emm77, whereas emm1, emm3, emm6, emm12, emm87 and emm89 were associated with macrolide susceptibility. A significant yearly fluctuation was observed in emm4, emm28 and emm77. The most common macrolide-resistant GAS were emm77 isolates harboring erm(A), either alone or in combination with mef(A), emm4 carrying mef(A), emm28 possessing erm(B), emm75 carrying mef(A), emm12 harboring mef(A) and emm22 carrying erm(A). We estimated that 82.8% of the isolates belonged to emm types included in the novel 26-valent M protein vaccine. The vaccine coverage rate was determined mainly by the increased frequency of nonvaccine emm4 isolates.
Conclusions
A limited number of emm types dominated among macrolide-susceptible and macrolide-resistant GAS isolates. We observed seasonal fluctuations, which were significant for emm4, emm28 and emm77. This type of data can serve as baseline information if the novel 26-valent M protein GAS vaccine is introduced into practice.
doi:10.1371/journal.pone.0071558
PMCID: PMC3747210  PMID: 23977078
3.  A dedicated surveillance network for congenital toxoplasmosis in Greece, 2006-2009: assessment of the results 
BMC Public Health  2012;12:1019.
Background
Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. Acute infections in pregnant women may be transmitted to the fetus and cause severe illness. The purpose of this study was to establish a dedicated surveillance network (DSN) for congenital toxoplasmosis (CT) in Greece, in order to assess the birth prevalence of CT.
Methods
A DSN of thirty clinicians was established for reporting CT cases from hospitals throughout Greece. The clinicians were selected on the basis that there was a high possibility the suspected cases would be referred to them from district hospitals or private clinics. Suspected cases of CT were reported on a monthly basis with a zero reporting card during a surveillance period from April 2006 to December 2009. A questionnaire was sent for any suspected case to record information including demographic parameters, clinical signs and symptoms and laboratory results. Serological and molecular confirmation of cases was performed by the Pasteur Hellenic Institute. All newborns suspected of CT received treatment and were serologically and clinically followed up for one year.
Results
The monthly response rate reached 100%, although only after reminders sent to 65% of the participant physicians. Sixty-three suspected CT cases were recorded by the DSN during the study period including fourteen confirmed and seven probable cases. Ten cases (47.6%) presented with symptoms at birth. Chorioretinitis was the most prominent manifestation, occurring in five symptomatic CT cases (50%). No other symptoms appeared by the end of the one year clinical follow up. No case was recorded by the existing surveillance system of the Hellenic Center of Disease Control and Prevention (HCDCP) during the same time period. Birth prevalence was estimated at 0.45, 0.51 and 0.51 per 10,000 births for 2007, 2008 and 2009 respectively. The incidence rate of symptomatic CT at birth was estimated at 0.10 cases per 10,000 births per year in Greece (for the period 2007–2009).
Conclusion
The DSN for CT proved to be more sensitive than the classical notification system, easy in application and very efficient in reporting rare diseases such as CT. Similar DSNs could be used to provide useful information on other rare diseases.
doi:10.1186/1471-2458-12-1019
PMCID: PMC3533839  PMID: 23173875
Congenital Toxoplasmosis; Surveillance Network; Greece
4.  Risk Factors of Antibiotic Misuse for Upper Respiratory Tract Infections in Children: Results from a Cross-Sectional Knowledge-Attitude-Practice Study in Greece 
ISRN Pediatrics  2012;2012:685302.
Background. Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to identify possible risk factors associated with antibiotic misuse in Greece, a country with high levels of antibiotic use and antibiotic resistance. Methods. A knowledge-attitude-practice (KAP) questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. Results. The sample of the study contained 5312 parents from all geographic areas of Greece. The risk factors of being a father, having low education, having immigrant status, being a single parent, having low income, having <2 or >3 children, living in the islands, and being without experience in recurrent URTIs were significantly associated to inadequate knowledge, inappropriate attitudes, and wrong practices. Conclusions. This study has identified the main groups of parents that should be targeted in future intervention programs.
doi:10.5402/2012/685302
PMCID: PMC3503327  PMID: 23209933
5.  Macrolide resistance determinants among Streptococcus pneumoniae isolates from carriers in Central Greece 
BMC Infectious Diseases  2012;12:255.
Background
We sought to characterize the temporal trends in nasopharyngeal carriage of macrolide-resistant pneumococci during a period with increased heptavalent pneumococcal conjugate vaccine (PCV7) coverage in Central Greece.
Methods
Streptococcus pneumoniae isolates were recovered from 2649 nasopharyngeal samples obtained from day-care center attendees in Central Greece during 2005–2009. A phenotypic and genotypic analysis of the isolates was performed, including the identification of macrolide resistance genes mef(A), subclasses mef(A) and mef(E), as well as erm(B).
Results
Of the 1105 typeable S. pneumoniae isolates, 265 (24%) were macrolide-resistant; 22% in 2005, 33.3% in 2006, 23.7% in 2007, and 20.5% in 2009 (P=0.398). Among these macrolide-resistant pneumococci, 28.5% possessed erm(B), 24.3% erm(B)+mef(E), 41.8% mef(E), and 5.3% mef(A). A mef gene as the sole resistance determinant was carried by 31% of macrolide-resistant isolates belonging to PCV7 serotypes and 75.8% of the non-PCV7 serotypes. Across the 4 annual surveillances, pneumococci carrying mef(A) gradually disappeared, whereas serotype 19F isolates carrying both erm(B) and mef(E) persisted without significant yearly fluctuations. Among isolates belonging to non-PCV7 serotypes, macrolide-resistance was observed in those of serotypes 6A, 19A, 10A, 15A, 15B/C, 35F, 35A, and 24F. In 2009, ie 5 years after the introduction of PCV7 in our country, 59% of macrolide-resistant pneumococci belonged to non-PCV7 serotypes.
Conclusions
Across the study period, the annual frequency of macrolide-resistant isolates did not change significantly, but in 2009 a marked shift to non-PCV7 serotypes occurred. Overall, more than half of the macrolide-resistant isolates possessed erm(B) either alone or in combination with mef(E). erm(B) dominated among isolates belonging to PCV7 serotypes, but not among those of non-PCV7 serotypes.
doi:10.1186/1471-2334-12-255
PMCID: PMC3484024  PMID: 23057516
6.  European ST80 community-associated methicillin-resistant Staphylococcus aureus orbital cellulitis in a neonate 
BMC Ophthalmology  2012;12:7.
Background
Methicillin-resistant Staphylococcus aureus is a serious cause of morbidity and mortality in hospital environment, but also, lately, in the community. This case report is, to our knowledge, the first detailed description of a community-associated methicillin-resistant S. aureus ST80 orbital cellulitis in a previously healthy neonate. Possible predisposing factors of microbial acquisition and treatment selection are also discussed.
Case presentation
A 28-day-old Caucasian boy was referred to our hospital with the diagnosis of right orbital cellulitis. His symptoms included right eye proptosis, periocular edema and redness. Empirical therapy of intravenous daptomycin, rifampin and ceftriaxone was initiated. The culture of pus yielded a methicillin-resistant S. aureus isolate and the molecular analysis revealed that it was a Panton-Valentine leukocidine-positive ST80 strain. The combination antimicrobial therapy was continued for 42 days and the infection was successfully controlled.
Conclusions
Clinicians should be aware that young infants, even without any predisposing condition, are susceptible to orbital cellulitis caused by community-associated methicillin-resistant S. aureus. Prompt initiation of the appropriate empirical therapy, according to the local epidemiology, should successfully address the infection, preventing ocular and systemic complications.
doi:10.1186/1471-2415-12-7
PMCID: PMC3352026  PMID: 22490061
Neonatal orbital cellulitis; Methicillin-resistant; Staphylococcus aureus; Daptomycin
7.  Descriptive Study on Parents’ Knowledge, Attitudes and Practices on Antibiotic Use and Misuse in Children with Upper Respiratory Tract Infections in Cyprus 
Upper respiratory tract infections (URTIs) are common in children and represent a significant cause of antibiotic abuse which contributes to the development of antibiotic resistance. A survey was conducted in Cyprus in 2006 to assess parents’ and pediatricians’ Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics in children with URTIs. A school-based stratified geographic clustering sampling was used and a pre-tested KAP questionnaire was distributed. A different questionnaire was distributed to paediatricians. Demographic factors associated with antibiotic misuse were identified by backward logistic regression analysis. The parental overall response rate was 69.3%. Parents (N = 1,462) follow pediatricians advice and rarely administer antibiotics acquired over the counter. Although a third expects an antibiotic prescription for URTI symptoms, most deny pressuring their doctors. Low parental education was the most important independent risk factor positively related to antibiotic misuse (OR = 2.88, 95%CI 2.02 to 4.12, p < 0.001). Pediatricians (N = 33) denied prescribing antibiotics after parental pressure but admit that parents ask for antibiotics and believe they expect antibiotic prescriptions even when not needed. In conclusion, Cypriotic parents trust their primary care providers. Although it appears that antibiotic misuse is not driven by parental pressure, the pediatricians’ view differs.
doi:10.3390/ijerph8083246
PMCID: PMC3166740  PMID: 21909304
antibiotics; bacterial resistance; KAP study; knowledge; attitudes; practices; antibiotic overuse; antibiotic misuse; questionnaire; parents
8.  Antibiotic use for upper respiratory tract infections in children: A cross-sectional survey of knowledge, attitudes, and practices (KAP) of parents in Greece 
BMC Pediatrics  2011;11:60.
Background
Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to document and analyse parental beliefs on antibiotic use for children with URTIs in Greece, a country with high levels of antibiotic use and antibiotic resistance.
Methods
A knowledge-attitude-practice questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. The sample of the study contained parents from all geographic areas of Greece.
Results
The majority of Greek parents (80%) believed that UTRIs are mostly self-limited, although 74% of them expected to receive antibiotics when such a diagnosis was given. Earache was the most common reason for which parents expected antibiotics (45%). Greek parents rarely gave antibiotics to their children without medical advice (10%) and most (88%) believed that unnecessary antibiotic use drives antibiotic resistance and they were happy to receive symptomatic therapy if instructed by their physician. Almost 70% of parents confused antibiotics with other medicines used for symptomatic therapy for a child with URTI.
Conclusion
Greek parents have a trusted relationship with their paediatrician and rarely give antibiotics without medical advice, indicating that parents contribute less than expected to antibiotic misuse. Parents also appreciate the benign course of most URTIs and the fact that unnecessary antibiotic use is harmful. More time needs to be invested in educating mostly physicians on the potential benefit from reducing antibiotic prescribing for children with URTI.
doi:10.1186/1471-2431-11-60
PMCID: PMC3141508  PMID: 21729266
9.  Fusidic acid and clindamycin resistance in community-associated, methicillin-resistant Staphylococcus aureus infections in children of Central Greece 
BMC Infectious Diseases  2010;10:351.
Introduction
In Greece, fusidic acid and clindamycin are commonly used for the empiric therapy of suspected staphylococcal infections.
Methods
The medical records of children examined at the outpatient clinics or admitted to the pediatric wards of the University General Hospital of Larissa, Central Greece, with community-associated staphylococcal infections from January 2003 to December 2009 were reviewed.
Results
Of 309 children (0-14 years old), 21 (6.8%) had invasive infections and 288 (93.2%) skin and soft tissue infections (SSTIs). Thirty-five patients were ≤30 days of age. The proportion of staphylococcal infections caused by a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) isolate increased from 51.5% (69 of 134) in 2003-2006 to 63.4% (111 of 175) in 2007-2009 (P = 0.037). Among the CA-MRSA isolates, 88.9% were resistant to fusidic acid, 77.6% to tetracycline, and 21.1% to clindamycin. Clindamycin resistance increased from 0% (2003) to 31.2% (2009) among the CA-MRSA isolates (P = 0.011). Over the 7-year period, an increase in multidrug-resistant CA-MRSA isolates was observed (P = 0.004). One hundred and thirty-one (93.6%) of the 140 tested MRSA isolates were Panton-Valentine leukocidin-positive. Multilocus sequence typing of 72 CA-MRSA isolates revealed that they belonged to ST80 (n = 61), ST30 (n = 6), ST377 (n = 3), ST22 (n = 1), and ST152 (n = 1). Resistance to fusidic acid was observed in ST80 (58/61), ST30 (1/6), and ST22 (1/1) isolates.
Conclusion
In areas with high rate of infections caused by multidrug-resistant CA-MRSA isolates, predominantly belonging to the European ST80 clone, fusidic acid and clindamycin should be used cautiously as empiric therapy in patients with suspected severe staphylococcal infections.
doi:10.1186/1471-2334-10-351
PMCID: PMC3019191  PMID: 21144056
10.  Development and assessment of a questionnaire for a descriptive cross – sectional study concerning parents' knowledge, attitudes and practises in antibiotic use in Greece 
Background
Upper Respiratory Infections (URIs) are common in children. The cause is usually viral, but parents' attitude often contributes to inappropriate antibiotic prescribing, promoting antibiotic resistance. The objective is to describe the process of developing a questionnaire to assess parents' Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics when children suffer from URIs, as well as to evaluate the response rates, the completeness and the reliability (Cronbach) of the questionnaires. Finally, to note any limitations of the study.
Methods
Literature review, along with pre – testing yielded a questionnaire designed to assess the parents' KAP – level. A postal survey was set, in a national sample of 200 schools stratified by geographical region. The participants consist of a multistage geographical cluster sample of 8000 parents. The influence of demographic characteristics (i.e. sex, age, education) was analyzed. Cronbach index test and factor analysis were used to assess the reliability of the questionnaire.
Results
The response rate of the parents was 69%. Islands presented the lowest response rate while in Northern Greece the response rate was the highest. Sixty – eight point nine percent of the sample returned questionnaires fully completed, while 91.5% completed 95% of the questions. Three questions out of 70 were answered in a very low rate which was associated mostly with immigrant respondents. The section describing parents' attitude toward antibiotic use was not completed as much as the sections of knowledge or practices. The questions were factor analyzed and 10 out of the 21 extracted factors were finally evaluated, reducing the number of independent variables to 46. The reliability of the questionnaire was 0.55. However, only items that increased the Cronbach when added were eventually included in the final scales raising the internal consistency to 0.68. Limitations of the study, such as the vocabulary and form of the questionnaire and the idiocycrancy of the respondents, emerged during the analysis.
Conclusion
The response rate and the completeness of the questionnaires were higher than expected, probably attributed to the involvement of the teachers. The study findings were satisfactory regarding the development of a reliable instrument capable to measure parents' KAP characteristics.
doi:10.1186/1471-2334-9-52
PMCID: PMC2686701  PMID: 19413902
11.  Resistance to Erythromycin and Telithromycin in Streptococcus pyogenes Isolates Obtained between 1999 and 2002 from Greek Children with Tonsillopharyngitis: Phenotypic and Genotypic Analysis 
Since the late 1990s, the prevalence of erythromycin-resistant Streptococcus pyogenes has significantly increased in several European countries. Between January 1999 and December 2002, 1,577 isolates of S. pyogenes were recovered from children with tonsillopharyngitis living in various areas of Western Greece. Erythromycin resistance was observed in 379 (24%) of the 1,577 isolates. All erythromycin-resistant strains along with 153 randomly selected erythromycin-susceptible S. pyogenes isolates were tested for their antimicrobial susceptibility, resistance phenotypes, and genotypes. Representative isolates underwent emm gene sequence typing. Isolates with reduced susceptibility to telithromycin (MIC, ≥2 μg/ml) were studied for multilocus sequence type, L22, L4, and 23S rRNA mutations. Of the total 379 erythromycin-resistant isolates, 193 (50.9%) harbored the mef(A) gene, 163 (43%) erm(A), 1 (0.3%) mef(A) plus erm(A), and 22 (5.8%) the erm(B) gene. Among the erythromycin-susceptible isolates, emm 1 (25%), emm 2 (12.5%), and emm 77 (12.5%) predominated. Furthermore, among the erythromycin-resistant isolates, emm 4 (30.6%), emm 28 (22.2%), and emm 77 (12.5%) prevailed. Resistance to telithromycin was observed in 22 (5.8%) of the erythromycin-resistant isolates. Sixteen (72.7%) of the 22 isolates appeared to be clonally related, since all of them belonged to emm type 28 and multilocus sequence type 52. One of the well-known mutations (T2166C) in 23S rRNA, as well as a new one (T2136C), was detected in erythromycin- and telithromycin-resistant isolates. High incidence of macrolide resistance and clonal spread of telithromycin resistance were the characteristics of the Greek S. pyogenes isolates obtained from 1999 to 2002.
doi:10.1128/AAC.50.1.256-261.2006
PMCID: PMC1346824  PMID: 16377695
12.  The UspA2 Protein of Moraxella catarrhalis Is Directly Involved in the Expression of Serum Resistance  
Infection and Immunity  2005;73(4):2400-2410.
Many strains of Moraxella catarrhalis are resistant to the bactericidal activity of normal human serum. Previous studies have shown that mutations involving the insertion of an antibiotic resistance cartridge into the M. catarrhalis uspA2 gene resulted in the conversion of a serum-resistant strain to a serum-sensitive phenotype. In the present study, the deletion of the entire uspA2 gene from the serum-resistant M. catarrhalis strain O35E resulted in a serum-sensitive phenotype and did not affect either the rate of growth or the lipooligosaccharide expression profile of this mutant. Inactivation of the classical complement pathway in normal human serum with Mg2+ and EGTA resulted in the survival of this uspA2 mutant. In contrast, blocking of the alternative complement pathway did not protect this uspA2 mutant from complement-mediated killing. To determine whether the UspA2 protein is directly involved in serum resistance, transformation and allelic exchange were used to replace the uspA2 gene in the serum-resistant strain O35E with the uspA2 gene from the serum-sensitive M. catarrhalis strain MC317. The resultant O35E transformant exhibited a serum-sensitive phenotype. Similarly, when the uspA2 gene from the serum-resistant strain O35E was used to replace the uspA2 gene in the serum-sensitive strain MC317, the MC317 transformant acquired serum resistance. The use of hybrid O35E-MC317 uspA2 genes showed that the N-terminal half of the O35E protein contained a 102-amino-acid region that was involved in the expression of serum resistance. In addition, when the uspA2 genes from strains O35E and MC317 were cloned and expressed in Haemophilus influenzae DB117, only the O35E UspA2 protein caused a significant increase in the serum resistance of the H. influenzae recombinant strain. These results prove that the UspA2 protein is directly involved in the expression of serum resistance by certain M. catarrhalis strains.
doi:10.1128/IAI.73.4.2400-2410.2005
PMCID: PMC1087425  PMID: 15784586
13.  Antimicrobial Susceptibility and Macrolide Resistance Inducibility of Streptococcus pneumoniae Carrying erm(A), erm(B), or mef(A) 
Erythromycin-resistant Streptococcus pneumoniae isolates from young carriers were tested for their antimicrobial susceptibility; additionally, inducibility of macrolide and clindamycin resistance was investigated in pneumococci carrying erm(A), erm(B), or mef(A). Of 125 strains tested, 101 (81%) were multidrug resistant. Different levels of induction were observed with erythromycin, miocamycin, and clindamycin in erm(B) strains; however, in erm(A) strains only erythromycin was an inducer. Induction did not affect macrolide MICs in mef(A) strains.
doi:10.1128/AAC.47.8.2699-2702.2003
PMCID: PMC166089  PMID: 12878546
14.  Identification of an erm(A) Erythromycin Resistance Methylase Gene in Streptococcus pneumoniae Isolated in Greece 
In a serotype 11A clone of erythromycin-resistant pneumococci isolated from young Greek carriers, we identified the nucleotide sequence of erm(A), a methylase gene previously described as erm(TR) in Streptococcus pyogenes. The erm(A) pneumococci were resistant to 14- and 15-member macrolides, inducibly resistant to clindamycin, and susceptible to streptogramin B. To our knowledge, this is the first identification of resistance to erythromycin in S. pneumoniae attributed solely to the carriage of the erm(A) gene.
doi:10.1128/AAC.45.1.342-344.2001
PMCID: PMC90289  PMID: 11120994
15.  Molecular Epidemiology of Penicillin-Nonsusceptible Streptococcus pneumoniae among Children in Greece 
Journal of Clinical Microbiology  2000;38(12):4361-4366.
A total of 145 penicillin-nonsusceptible Streptococcus pneumoniae strains were isolated from young carriers in Greece and analyzed by antibiotic susceptibility testing, serotyping, restriction fragment end labeling (RFEL), and penicillin-binding protein (PBP) genotyping. The serotypes 23A and 23F (54%), 19A and 19F (25%), 9V (5%), 15A, 15B, and 15C (4%), 6A and 6B (4%), and 21 (4%) were most prevalent in this collection. Fifty-three distinct RFEL types were identified. Sixteen different RFEL clusters, harboring 2 to 32 strains each, accounted for 82% of all strains. Eight of these genetic clusters representing 60% of the strains were previously identified in other countries. A predominant lineage of 66 strains (46%) harboring five RFEL types and the serotypes 19F and 23F was closely related to the pandemic clone Spain23F-1 (genetic relatedness of ≥85%). Another lineage, representing 11 strains, showed close genetic relatedness to the pandemic clone France9V-3. Another lineage of 8 serotype 21 strains was Greece specific since the RFEL types were not observed in an international collection of 193 genotypes from 16 different countries. Characterization of the PBP genes pbp1a, pbp2b, and pbp2x revealed 20 distinct PBP genotypes of which PBP type 1-1-1, initially observed in the pandemic clones 23F and 9V, was predominantly present in 11 RFEL types in this Greek collection of penicillin-nonsusceptible strains (55%). Sixteen PBP types covering 52 strains (36%) were Greece specific. This study underlines the strong contribution of penicillin-resistant international clones to the prevalence and spread of penicillin-nonsusceptible pneumococci among young children in Greece.
PMCID: PMC87606  PMID: 11101565

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