European Journal of Clinical Microbiology & Infectious Diseases, 2002
. The purpose of this double-blind study was to assess the effect of azithromycin and clarithro... more . The purpose of this double-blind study was to assess the effect of azithromycin and clarithromycin on oral and fecal microflora. Bacterial species from fecal samples and throat washes from healthy volunteers were identified and quantified before, during and after receipt of either placebo (n=6), azithromycin (500 mg once daily for 3 days; n=6) or clarithromycin (500 mg twice daily
Background Dengue is an emerging infectious disease of global significance. Suspected dengue, esp... more Background Dengue is an emerging infectious disease of global significance. Suspected dengue, especially in children in Nicaragua's heavily-urbanized capital of Managua, has been well documented, but unsuspected dengue among children and adults with undifferentitated fever has not.
International Journal of Infectious Diseases, May 1, 2009
Background: In order to develop guidelines for the use of antimicrobial agents, it is necessary t... more Background: In order to develop guidelines for the use of antimicrobial agents, it is necessary to obtain detailed information on the prevalence of infectious diseases and antibiotic usage. Methods: A retrospective study was conducted among outpatients with acute infections visiting the emergency department of the University Hospital of León, Nicaragua. Results: Over the course of one month, 2027 patients visited the emergency department. Seven hundred and thirty-two patients (36.1%) had an infection, with a total of 799 acute infections. The majority of patients (55.9%) were children. Respiratory tract infections (43.4%), urogenital infections (29.5%), and diarrhea or gastroenteritis of presumed infectious origin (8.8%) were the most frequent infections. Among respiratory tract infections, the most frequent diagnoses were community-acquired pneumonia (CAP; 31.4%), acute tonsillitis (28.2%), and the common cold (17.6%). CAP was treated with procaine benzylpenicillin in 70.6% of cases, whereas 84.0% of patients with acute tonsillitis were treated with a single dosage of benzathine benzylpenicillin intramuscularly. Among urogenital infections, the most frequent diagnosis was acute uncomplicated urinary tract infection (24.2%). Approximately a quarter of patients with uncomplicated urinary tract infections did not receive treatment according to the local guidelines. Of the patients with acute diarrhea, 27.1% were treated with antibiotics, while only a minority had leukocytes in Wright stain of the feces. Conclusions: In conclusion our study shows that the use of antimicrobial agents is not optimal. Antibiotics were prescribed too often and not according to the local guidelines. This will further exacerbate the resistance problem in Nicaragua.
Background: To determine adherence to the guideline for preoperative antibiotic use in Nicaragua.... more Background: To determine adherence to the guideline for preoperative antibiotic use in Nicaragua. Methods: An observational study in the University Hospital of León, Nicaragua. All surgical patients in the departments of general surgery, orthopaedics, gynaecology and obstetrics, and paediatrics during a four-week period were included. Patients with infections prior to surgery were excluded. Main outcome measures were the proportion of patients that received appropriate preoperative antibiotics based on wound classification, suspected pathogens, administered antibiotics (type and dose), therapy duration and timing according to the local protocol. Results: In the study, 297 patients received a total of 395 antibiotics with 2595 doses for a total of 1087 days. Only 68% of patients received antibiotic prophylaxis for indications mentioned in the protocol. Antibiotics were given without indication or as treatment in 23%. In 9% of the cases no preoperative antibiotic therapy was given (no indication for 6%, but indicated for 3%). Of the 201 patients with an indication for prophylaxis, 25% received more antibiotic therapies than indicated. Antibiotic choice was discordant with the protocol in 69%, dose in 20%, and both the moment of administration and duration in 78%. Overall adherence was achieved in 7% of patients. Complete protocol violations were observed in 12%. The 243 patients in the prophylaxis group received 1707 doses, 83% of which were administered unnecessarily. Conclusion: Protocol violations are frequent in preoperative antibiotic prophylaxis in Nicaragua leading to considerable overprescription. Educational strategies to reinforce protocolised antibiotic use are essential for reducing costs and antibiotic resistance rates.
European Journal of Clinical Microbiology & Infectious Diseases, Dec 1, 2000
treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis [9]. Intravenous plus intr... more treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis [9]. Intravenous plus intrathecal polymyxin B has also been used in a case of meningitis due to multiresistant Acinetobacter baumannii [10]. Recently, intrathecal colistin sulfomethate sodium plus intravenous tobramycin has been used with good results in two cases of ventriculitis due to moderately tobramycin-resistant and carbapenem-resistant Acinetobacter baumannii [5]. However, the administration of intrathecal polymyxins B and E requires a temporary external ventriculostomy, a procedure associated with increased morbidity. Moreover, the clinical efficacy of intraventricular treatment with colistin is difficult to evaluate in patients with continuous CSF drainage, in whom CSF pharmacokinetics are variable [5].
International Journal of Antimicrobial Agents, Nov 1, 2006
We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance ... more We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance and risk factors for community-acquired pneumonia (CAP) in the region of León, Nicaragua. During the period from July 2002 to January 2005, all consecutive patients with signs and symptoms suggestive of CAP were included in the study. Sputum samples, paired serum samples and urinary samples were collected for the detection of respiratory pathogens. The most frequently identified pathogens were Streptococcus pneumoniae (17%), followed by Staphylococcus aureus (5%), Chlamydia pneumoniae (5%) and Mycoplasma pneumoniae (4%). Pseudomonas aeruginosa was cultured from 5% of patients. No pathogens were identified in 55%. All tested S. pneumoniae were sensitive to erythromycin and penicillin. In contrast, resistance of S. aureus to penicillin and erythromycin was high.
European Journal of Clinical Microbiology & Infectious Diseases, Oct 27, 2007
The purpose of this study was to describe the epidemic of clinically apparent human immunodeficie... more The purpose of this study was to describe the epidemic of clinically apparent human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) infection in Nicaragua and to discuss the reasons why the number of HIV patients presenting to the public health care system is increasing compared with other Central American countries. From 1987 to 2004, 1,614 HIV-positive patients were officially reported to the Nicaraguan STI/HIV/AIDS national program. Urban areas along the west-central and eastern part of Nicaragua showed the highest prevalence of AIDS, with a maximum of 54.2/year per 100,000 inhabitants. Most of the infections (91%) were acquired sexually: 65% by heterosexual contacts and 26% by homosexual contacts. The highest rate of infection was found in men aged between 20 to 39 years, with a peak around 35 to 39 years (annual incidence of 125.6 new cases per 100,000 inhabitants), and in women aged 20 to 34 years old, with a peak around 20 to 24 years (annual incidence 46.6 per 100,000 inhabitants). The male to female ratio of infection was 3:1. The death rate was stable until the beginning of 1999, but increased sharply thereafter up to 2004, the year that highly active antiretroviral therapy (HAART) was introduced in Nicaragua. In 2005, we observed a further increase in the mortality. However, our data do not represent the magnitude of the HIV/AIDS epidemic as a whole, due to a lack of systemic surveillance. HIV/AIDS in Nicaragua is in a nascent stage and is concentrated in highrisk populations, such as utility workers, commercial sex workers, men who have sex with men, prisoners, street children, housewives and police and military forces. Education of the population is an urgent need to increase HIV/AIDS-related knowledge, change attitudes, and increase safer sex practice in the community.
International Journal of Infectious Diseases, 2010
Background: The worldwide increasing resistance to antibiotics has complicated antimicrobial trea... more Background: The worldwide increasing resistance to antibiotics has complicated antimicrobial treatment of urinary tract infections (UTIs), especially in Latin America. This study aimed to report the present etiology and antimicrobial susceptibility of UTIs, and the effects of the national guidelines for UTIs introduced in 2003. Methods: Urine samples were collected from 304 patients with a clinical suspicion of UTI at the university hospital and primary health centers of Leó n, Nicaragua. When bacterial growth was reported, antimicrobial susceptibility tests for nine frequently used antibiotics were performed. Results: Ninety-one (29.9%) patients had a positive urine culture. The most frequently isolated microorganisms were Escherichia coli (n = 44), Serratia spp (n = 11), and Escherichia fergusonii (n = 10). High resistance rates were observed in E. coli to ampicillin (61.4%), cefalothin (45.5%), trimethoprimsulfamethoxazole (38.6%), ciprofloxacin (31.8%), and ceftriaxone (20.5%). Amikacin and nitrofurantoin were the only drugs to which >90% of E. coli were susceptible. E. fergusonii and Serratia spp showed comparable high resistance patterns. Thirteen strains (29.5%) of E. coli were suspected to produce extended-spectrum beta-lactamase (ESBL). Conclusions: Resistance rates in community-acquired UTIs in Nicaragua are increasing. The introduction of therapeutic guidelines with ceftriaxone recommended for upper UTIs and nitrofurantoin for lower UTIs, has led to increasing resistance against both antibiotics. The emergence of ESBL-producing E. coli is worrisome, along with the appearance of Serratia spp in the population.
International Journal of Antimicrobial Agents, 2004
Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is comp... more Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of León, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria >/=10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as >/=10(5) cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby-Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in León and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (>90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC(90) 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC(90) 32 mg/l), cephalothin (58%, MIC(90), 32 mg/l), ciprofloxacin (30%; MIC(90), 32 mg/l), amoxicillin/clavulanate (21%, MIC(90) 8 mg/l) and gentamicin (12%, MIC(90) 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern.
<p>Note that the IFA substrate slides used resulted in simultaneous tests for both <i>... more <p>Note that the IFA substrate slides used resulted in simultaneous tests for both <i>R</i>. <i>rickettsii</i> and <i>R</i>. <i>typhi</i>; those samples identified with <i>R</i>. <i>rickettsii</i> IFA antibodies were then included in the <i>R</i>. <i>rickettsii</i> tally (<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0005185#pntd.0005185.g001" target="_blank">Fig 1</a>) if not <i>R</i>. <i>rickettsii</i> ELISA reactive.</p
#<p>Does not sum to 100% secondary to rounding.</p><p>*Sums to greater than 100... more #<p>Does not sum to 100% secondary to rounding.</p><p>*Sums to greater than 100% secondary to multiple exposures.</p
<p>Clinical characteristics of febrile patients with confirmed acute rickettsial infection ... more <p>Clinical characteristics of febrile patients with confirmed acute rickettsial infection vs. no acute rickettsial infection, Nicaragua.</p
<p>Clinical characteristics of febrile patients with acute Q fever vs. no acute Q fever, Ni... more <p>Clinical characteristics of febrile patients with acute Q fever vs. no acute Q fever, Nicaragua.</p
<p>Epidemiologic characteristics of patients with definitive serologic evidence of Q fever ... more <p>Epidemiologic characteristics of patients with definitive serologic evidence of Q fever vs. no Q fever, Nicaragua</p
<p>Study participants with a diagnosis of confirmed acute leptospirosis, Nicaragua 2008–9.&... more <p>Study participants with a diagnosis of confirmed acute leptospirosis, Nicaragua 2008–9.</p
European Journal of Clinical Microbiology & Infectious Diseases, 2002
. The purpose of this double-blind study was to assess the effect of azithromycin and clarithro... more . The purpose of this double-blind study was to assess the effect of azithromycin and clarithromycin on oral and fecal microflora. Bacterial species from fecal samples and throat washes from healthy volunteers were identified and quantified before, during and after receipt of either placebo (n=6), azithromycin (500 mg once daily for 3 days; n=6) or clarithromycin (500 mg twice daily
Background Dengue is an emerging infectious disease of global significance. Suspected dengue, esp... more Background Dengue is an emerging infectious disease of global significance. Suspected dengue, especially in children in Nicaragua's heavily-urbanized capital of Managua, has been well documented, but unsuspected dengue among children and adults with undifferentitated fever has not.
International Journal of Infectious Diseases, May 1, 2009
Background: In order to develop guidelines for the use of antimicrobial agents, it is necessary t... more Background: In order to develop guidelines for the use of antimicrobial agents, it is necessary to obtain detailed information on the prevalence of infectious diseases and antibiotic usage. Methods: A retrospective study was conducted among outpatients with acute infections visiting the emergency department of the University Hospital of León, Nicaragua. Results: Over the course of one month, 2027 patients visited the emergency department. Seven hundred and thirty-two patients (36.1%) had an infection, with a total of 799 acute infections. The majority of patients (55.9%) were children. Respiratory tract infections (43.4%), urogenital infections (29.5%), and diarrhea or gastroenteritis of presumed infectious origin (8.8%) were the most frequent infections. Among respiratory tract infections, the most frequent diagnoses were community-acquired pneumonia (CAP; 31.4%), acute tonsillitis (28.2%), and the common cold (17.6%). CAP was treated with procaine benzylpenicillin in 70.6% of cases, whereas 84.0% of patients with acute tonsillitis were treated with a single dosage of benzathine benzylpenicillin intramuscularly. Among urogenital infections, the most frequent diagnosis was acute uncomplicated urinary tract infection (24.2%). Approximately a quarter of patients with uncomplicated urinary tract infections did not receive treatment according to the local guidelines. Of the patients with acute diarrhea, 27.1% were treated with antibiotics, while only a minority had leukocytes in Wright stain of the feces. Conclusions: In conclusion our study shows that the use of antimicrobial agents is not optimal. Antibiotics were prescribed too often and not according to the local guidelines. This will further exacerbate the resistance problem in Nicaragua.
Background: To determine adherence to the guideline for preoperative antibiotic use in Nicaragua.... more Background: To determine adherence to the guideline for preoperative antibiotic use in Nicaragua. Methods: An observational study in the University Hospital of León, Nicaragua. All surgical patients in the departments of general surgery, orthopaedics, gynaecology and obstetrics, and paediatrics during a four-week period were included. Patients with infections prior to surgery were excluded. Main outcome measures were the proportion of patients that received appropriate preoperative antibiotics based on wound classification, suspected pathogens, administered antibiotics (type and dose), therapy duration and timing according to the local protocol. Results: In the study, 297 patients received a total of 395 antibiotics with 2595 doses for a total of 1087 days. Only 68% of patients received antibiotic prophylaxis for indications mentioned in the protocol. Antibiotics were given without indication or as treatment in 23%. In 9% of the cases no preoperative antibiotic therapy was given (no indication for 6%, but indicated for 3%). Of the 201 patients with an indication for prophylaxis, 25% received more antibiotic therapies than indicated. Antibiotic choice was discordant with the protocol in 69%, dose in 20%, and both the moment of administration and duration in 78%. Overall adherence was achieved in 7% of patients. Complete protocol violations were observed in 12%. The 243 patients in the prophylaxis group received 1707 doses, 83% of which were administered unnecessarily. Conclusion: Protocol violations are frequent in preoperative antibiotic prophylaxis in Nicaragua leading to considerable overprescription. Educational strategies to reinforce protocolised antibiotic use are essential for reducing costs and antibiotic resistance rates.
European Journal of Clinical Microbiology & Infectious Diseases, Dec 1, 2000
treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis [9]. Intravenous plus intr... more treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis [9]. Intravenous plus intrathecal polymyxin B has also been used in a case of meningitis due to multiresistant Acinetobacter baumannii [10]. Recently, intrathecal colistin sulfomethate sodium plus intravenous tobramycin has been used with good results in two cases of ventriculitis due to moderately tobramycin-resistant and carbapenem-resistant Acinetobacter baumannii [5]. However, the administration of intrathecal polymyxins B and E requires a temporary external ventriculostomy, a procedure associated with increased morbidity. Moreover, the clinical efficacy of intraventricular treatment with colistin is difficult to evaluate in patients with continuous CSF drainage, in whom CSF pharmacokinetics are variable [5].
International Journal of Antimicrobial Agents, Nov 1, 2006
We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance ... more We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance and risk factors for community-acquired pneumonia (CAP) in the region of León, Nicaragua. During the period from July 2002 to January 2005, all consecutive patients with signs and symptoms suggestive of CAP were included in the study. Sputum samples, paired serum samples and urinary samples were collected for the detection of respiratory pathogens. The most frequently identified pathogens were Streptococcus pneumoniae (17%), followed by Staphylococcus aureus (5%), Chlamydia pneumoniae (5%) and Mycoplasma pneumoniae (4%). Pseudomonas aeruginosa was cultured from 5% of patients. No pathogens were identified in 55%. All tested S. pneumoniae were sensitive to erythromycin and penicillin. In contrast, resistance of S. aureus to penicillin and erythromycin was high.
European Journal of Clinical Microbiology & Infectious Diseases, Oct 27, 2007
The purpose of this study was to describe the epidemic of clinically apparent human immunodeficie... more The purpose of this study was to describe the epidemic of clinically apparent human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) infection in Nicaragua and to discuss the reasons why the number of HIV patients presenting to the public health care system is increasing compared with other Central American countries. From 1987 to 2004, 1,614 HIV-positive patients were officially reported to the Nicaraguan STI/HIV/AIDS national program. Urban areas along the west-central and eastern part of Nicaragua showed the highest prevalence of AIDS, with a maximum of 54.2/year per 100,000 inhabitants. Most of the infections (91%) were acquired sexually: 65% by heterosexual contacts and 26% by homosexual contacts. The highest rate of infection was found in men aged between 20 to 39 years, with a peak around 35 to 39 years (annual incidence of 125.6 new cases per 100,000 inhabitants), and in women aged 20 to 34 years old, with a peak around 20 to 24 years (annual incidence 46.6 per 100,000 inhabitants). The male to female ratio of infection was 3:1. The death rate was stable until the beginning of 1999, but increased sharply thereafter up to 2004, the year that highly active antiretroviral therapy (HAART) was introduced in Nicaragua. In 2005, we observed a further increase in the mortality. However, our data do not represent the magnitude of the HIV/AIDS epidemic as a whole, due to a lack of systemic surveillance. HIV/AIDS in Nicaragua is in a nascent stage and is concentrated in highrisk populations, such as utility workers, commercial sex workers, men who have sex with men, prisoners, street children, housewives and police and military forces. Education of the population is an urgent need to increase HIV/AIDS-related knowledge, change attitudes, and increase safer sex practice in the community.
International Journal of Infectious Diseases, 2010
Background: The worldwide increasing resistance to antibiotics has complicated antimicrobial trea... more Background: The worldwide increasing resistance to antibiotics has complicated antimicrobial treatment of urinary tract infections (UTIs), especially in Latin America. This study aimed to report the present etiology and antimicrobial susceptibility of UTIs, and the effects of the national guidelines for UTIs introduced in 2003. Methods: Urine samples were collected from 304 patients with a clinical suspicion of UTI at the university hospital and primary health centers of Leó n, Nicaragua. When bacterial growth was reported, antimicrobial susceptibility tests for nine frequently used antibiotics were performed. Results: Ninety-one (29.9%) patients had a positive urine culture. The most frequently isolated microorganisms were Escherichia coli (n = 44), Serratia spp (n = 11), and Escherichia fergusonii (n = 10). High resistance rates were observed in E. coli to ampicillin (61.4%), cefalothin (45.5%), trimethoprimsulfamethoxazole (38.6%), ciprofloxacin (31.8%), and ceftriaxone (20.5%). Amikacin and nitrofurantoin were the only drugs to which >90% of E. coli were susceptible. E. fergusonii and Serratia spp showed comparable high resistance patterns. Thirteen strains (29.5%) of E. coli were suspected to produce extended-spectrum beta-lactamase (ESBL). Conclusions: Resistance rates in community-acquired UTIs in Nicaragua are increasing. The introduction of therapeutic guidelines with ceftriaxone recommended for upper UTIs and nitrofurantoin for lower UTIs, has led to increasing resistance against both antibiotics. The emergence of ESBL-producing E. coli is worrisome, along with the appearance of Serratia spp in the population.
International Journal of Antimicrobial Agents, 2004
Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is comp... more Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of León, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria &gt;/=10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as &gt;/=10(5) cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby-Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in León and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (&gt;90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC(90) 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC(90) 32 mg/l), cephalothin (58%, MIC(90), 32 mg/l), ciprofloxacin (30%; MIC(90), 32 mg/l), amoxicillin/clavulanate (21%, MIC(90) 8 mg/l) and gentamicin (12%, MIC(90) 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern.
<p>Note that the IFA substrate slides used resulted in simultaneous tests for both <i>... more <p>Note that the IFA substrate slides used resulted in simultaneous tests for both <i>R</i>. <i>rickettsii</i> and <i>R</i>. <i>typhi</i>; those samples identified with <i>R</i>. <i>rickettsii</i> IFA antibodies were then included in the <i>R</i>. <i>rickettsii</i> tally (<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0005185#pntd.0005185.g001" target="_blank">Fig 1</a>) if not <i>R</i>. <i>rickettsii</i> ELISA reactive.</p
#<p>Does not sum to 100% secondary to rounding.</p><p>*Sums to greater than 100... more #<p>Does not sum to 100% secondary to rounding.</p><p>*Sums to greater than 100% secondary to multiple exposures.</p
<p>Clinical characteristics of febrile patients with confirmed acute rickettsial infection ... more <p>Clinical characteristics of febrile patients with confirmed acute rickettsial infection vs. no acute rickettsial infection, Nicaragua.</p
<p>Clinical characteristics of febrile patients with acute Q fever vs. no acute Q fever, Ni... more <p>Clinical characteristics of febrile patients with acute Q fever vs. no acute Q fever, Nicaragua.</p
<p>Epidemiologic characteristics of patients with definitive serologic evidence of Q fever ... more <p>Epidemiologic characteristics of patients with definitive serologic evidence of Q fever vs. no Q fever, Nicaragua</p
<p>Study participants with a diagnosis of confirmed acute leptospirosis, Nicaragua 2008–9.&... more <p>Study participants with a diagnosis of confirmed acute leptospirosis, Nicaragua 2008–9.</p
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