Search Results (90)

Feline urinary tract infections (UTIs) present a common challenge in veterinary practice, underscoring the importance of understanding local bacterial pathogens and antimicrobial resistance (AMR). This study determined bacterial prevalence and antimicrobial susceptibility in cats at Kasetsart University’s Veterinary Teaching Hospital in Bangkok, Thailand. Of the 543 cystocentesis urine samples collected from 428 cats, 115 (21.2%) tested positive for bacterial cultures, leading to a diagnosis of UTIs in 95 cats (22.2%). The most prevalent isolates included Escherichia coli (24.8%), Staphylococcus species (19.2%), Proteus mirabilis (13.6%), Pseudomonas aeruginosa (12.0%), and Enterococcus species (12.0%). Staphylococcus felis (8.8%) and Staphylococcus pseudintermedius (5.6%) were the predominant Staphylococcus species. Rare pathogens such as Corynebacterium urealyticum and Lactococcus garvieae were also identified. Antimicrobial testing revealed alarming resistance, with 69.2% of isolates exhibiting multidrug resistance (MDR). Escherichia coli and Proteus mirabilis showed high resistance to amoxicillin/clavulanic acid (AMC) (45.2–70.6%) and sulfamethoxazole/trimethoprim (SXT) (51.6–52.9%). Enterococcus faecium exhibited 85.7% resistance to AMC. Methicillin resistance was identified in 41.7% of Staphylococcus isolates, particularly high in Staphylococcus epidermidis (75.0%) and Staphylococcus pseudintermedius (71.4%). High fluoroquinolone resistance among MDR isolates further exacerbates AMR concerns. These results indicate that MDR Gram-negative, Staphylococcus, and Enterococcus species complicate the empirical treatment of feline UTIs, highlighting significant implications for AMR in veterinary practice. Full article

Background/Objectives: European hedgehogs (Erinaceus europaeus) are present in areas where there is human activity; therefore, they can be a source of pathogens for other animals and humans. Methods: Eighteen hedgehog carcasses were collected and analyzed for Staphylococcus spp. Isolated strains were typed and analyzed for exfoliative toxins genes and the phenotypic and genotypic characteristics of antimicrobial resistance. Results: A total of 54 strains were isolated and typed as S. aureus, S. xylosus, S. sciuri, S. pseudintermedius, S. simulans, S. chromogenes, S. epidermidis, S. hyicus, and S. lentus. No strains had the eta and etb genes coding for exfoliative toxins. Overall, 39/54 (72.20%) isolates showed phenotypic resistance to at least one antimicrobial and 21/54 (38.80%) showed more than one resistance. The lowest efficacy was observed for erythromycin, with 40/54 (74.08%) strains classified as intermediate and 6/54 (11.11%) classified as resistant. Among the 29 isolates shown to be penicillin-resistant, 11 (37.93%) were oxacillin-resistant, with a minimum inhibitory concentration (MIC). Among the 54 staphylococcal strains, 2 (3.70%) were resistant to vancomycin, both with an MIC value equal to the maximum concentration of the antibiotic tested (256 μg/mL) and 2 (3.70%) had an intermediate resistance profile with an 8 μg/mL MIC value. No strains had the genes vanA and vanB. Two of the 29 (6.90%) penicillin-resistant strains had the blaZ gene; 8 (27.13%) strains had the mecA gene. Overall, 2/54 (3.70%) isolates were classified as extensively drug-resistant (XDR) and 9/54 (16.66%) were classified as multidrug-resistant (MDR). Conclusions: Hedgehogs can harbor antimicrobial-resistant staphylococci and can be sources of these bacteria for other animals and humans. They can also serve as bioindicators of the pathogens and antimicrobial-resistant bacteria circulating in a given habitat. Full article

Infections caused by oxacillin-resistant Staphylococcus pseudintermedius are increasingly common in veterinary medicine. The indiscriminate use of antibiotics by pet owners worsens this problem, reducing treatment efficacy and creating the need for alternative therapies. This study aimed to evaluate the inhibitory effect of clove essential oil (Syzygium aromaticum) on both oxacillin-resistant and susceptible S. pseudintermedius. Thirty-five isolates from dogs with otitis externa were analyzed. The bacteria were identified by phenotypic tests and tested for susceptibility to 22 antibiotics using disk diffusion. Resistance genes (mecA and blaZ) were detected using conventional PCR. Among the isolates, 34.28% (12/35) were positive for mecA, and 97.14% (34/35) for blaZ. The essential oil’s efficacy was assessed using broth microdilution to determine its minimum inhibitory concentration (MIC). Clove oil showed an average MIC and minimum bactericidal concentration (MBC) of 6.4 mg/mL, inhibiting both resistant and susceptible isolates. In conclusion, clove essential oil demonstrated in vitro antimicrobial activity against S. pseudintermedius. Full article

Background: Canine pyoderma and otitis externa are prevalent bacterial skin infections in veterinary practice, frequently complicated by the emergence of multidrug-resistant (MDR) pathogens. Objectives: To investigate the frequency, antimicrobial resistance (AMR) profiles, and frequency of MDR bacterial isolates from dogs with pyoderma or otitis externa in Hong Kong. Methods: A retrospective study of bacterial isolates from 215 clinical samples collected from dogs presenting with pyoderma (n = 63) or otitis externa (n = 152) at veterinary clinics across Hong Kong between 2018 and 2022. Bacterial isolates were identified and subjected to antimicrobial susceptibility testing against 13 antimicrobial classes. Results: Staphylococcus spp., particularly S. pseudintermedius, were the most commonly isolated species, followed by Pseudomonas spp. and Proteus spp. High resistance rates were observed for orbifloxacin (61.3% in pyoderma; 76.7% in otitis externa), doxycycline (59.3%; 69.2%), clindamycin (62%; 68.9%), and enrofloxacin (50%; 55.5%). Most isolates were sensitive to ofloxacin, ticarcillin–clavulanate, tobramycin, ciprofloxacin, cefpodoxime, cefuroxime, and cefixime. MDR was detected in 67.5% of pyoderma and 66.8% of otitis externa isolates. Gram-negative bacteria exhibited significantly higher MDR rates than Gram-positive isolates. The multiple antibiotic resistance (MAR) index averaged 0.41 for pyoderma and 0.52 for otitis externa isolates. We found no significant associations between MDR and non-modifiable risk factors (i.e., age, sex, breed, and reproductive status). Conclusions: These findings highlight the critical need for prudent antimicrobial use and continuous surveillance of AMR trends in companion animals. A higher focus should be placed on topical antiseptic therapy, with oral antibiotics used only in exceptional cases and after susceptibility testing. From a One Health perspective, the potential transmission of MDR bacteria between companion animals and humans underscores the importance of a coordinated approach to antimicrobial stewardship across both veterinary and human medicine. Full article

Staphylococcus pseudintermedius, an opportunistic pathogen of veterinary and zoonotic concern, harbors diverse biosynthetic gene clusters (BGCs) that may contribute to its ecological fitness and virulence. In this study, we performed a comparative genomic analysis of 6815 S. pseudintermedius isolates. Using Roary, we identified core and accessory genomes, revealing the subtilosin A gene (sboA) as part of the accessory genome, present in a subset of S. pseudintermedius isolates from clinical (n = 657), environmental (n = 1031), and unclassified sources (n = 487). AntiSMASH v8.0.0 analysis confirmed the presence of subtilosin A BGCs annotated as a sactipeptide with low similarity confidence to Bacillus subtilis subsp. spizizenii ATCC 6633 subtilosin A cluster. Further characterization using BAGEL4 identified multiple genes homologous to the Bacillus subtilis subtilosin A biosynthetic machinery (sbo-albABCDEFG), although albB, albG, and sboX were not annotated, raising questions about cluster completeness and functionality. BLAST v2.12.0 analysis of the full BGC identified by BAGEL4, revealing high conservation (99.6–100% pairwise identity) of gene content and order in 395 clinical, 593 environmental, and 417 unclassified S. pseudintermedius isolates. Incomplete clusters were identified in 763 clinical, 942 environmental, and 201 unclassified S. pseudintermedius isolates. The discrepancy between the number of isolates containing sboA and those harboring the full cluster may reflect evolutionary divergence or could be attributed to limitations in assembly quality. The functional implications of the identified cluster in S. pseudintermedius remain to be elucidated; however, its potential role in conferring competitive fitness by inhibiting closely related species is supported by previous findings in other staphylococci. Full article

Background: Pyoderma is a superficial bacterial infection that is considered the formation of pus-containing lesions on the skin occurring in animals. Staphylococci, including Staphylococcus aureus and Staphylococcus pseudintermedius, that cause pyoderma in pet animals is a global health concern. The objectives of this study were to investigate antibiotic-resistant staphylococci isolated from pyoderma in dogs and cats and to analyse whole genome sequences of multidrug-resistant (MDR) staphylococci. Methods: A total of 56 pyoderma swabbing samples from 42 dogs and 14 cats located in Southern Thailand was collected to isolate staphylococci. Antibiotic susceptibility and antibiotic-resistant genes of staphylococcal isolates were investigated. Furthermore, the representative MDR isolates were investigated using whole genome sequence analysis. Results: 61 isolates were identified as staphylococci, which can be classified into 12 different species, mostly including 13 S. intermedius (13.26%), 13 S. saprophyticus (13.26%), 8 S. sciuri (8.16%), and Staphylococcus cohnii (8.16%). Remarkably, the main pyoderma-causing species that were isolated in this study were S. aureus (5.10%) and S. pseudintermedius (3.06%). Most staphylococci were resistant to penicillin G (30%), and the blaZ gene was found to be the highest prevalence of the resistance genes. Both MDR-S. aureus WU1-1 and MDR-S. pseudintermedius WU48-1 carried capsule-related genes as main virulence factor genes. Interestingly, MDR-S. pseudintermedius WU48-1 was resistant to seven antibiotic classes, which simultaneously carried blaZ, mecA, aac, dfrK, aph3, and tetM. Genes related to antibiotic efflux were the highest proportion of the mechanism found in both representatives. Remarkably, SCCmec cassette genes were found in both isolates; however, the mecA gene was found only in MDR-S. pseudintermedius WU48-1. In addition, these were mostly carried by macrolide- and tetracycline-resistance genes. Mobile gene transfer and horizontal gene transfer events frequently contain genes involved in the antibiotic target alteration mechanism. Conclusions: This study found that MDR staphylococci, especially S. aureus and S. pseudintermedius, are important in animals and owners in terms of One Health concern. The information on whole genome sequences of these MDR staphylococci, particularly antimicrobial resistance genes, mobile genetic elements, and horizontal gene transfer events, can help to understand gene transmission and be applied for antibiotic resistance surveillance in veterinary medicine. Full article

Staphylococci are common pathogens in dogs, causing a variety of dermatological problems. This study aimed to characterize the prevalence, antibiotic resistance, and biofilm-forming potential of Staphylococcus species isolated from the skin of shelter dogs. Overall, 108 samples were collected from the hairless skin areas of dogs in a shelter over one year. Isolates were cultured using standard microbiological methods and identified through biochemical testing, MALDI-TOF MS, and multiplex PCR. A total of 67 Staphylococcus isolates were identified, with S. pseudintermedius being the most prevalent. Antibiotic susceptibility was assessed using disk diffusion and MIC methods, revealing high resistance to ampicillin, erythromycin, and tetracycline. Notably, 12 multidrug-resistant SIG (S. intermedius group; S. pseudintermedius) and 4 CoNS strains (coagulase-negative staphylococci; S. equorum) were identified. Biofilm production was evaluated using a crystal violet assay, showing variable biofilm-forming capabilities among isolates and PCR, to confirm genes associated with biofilm formation. These findings highlight the presence of multidrug-resistant Staphylococcus species in shelter dogs, emphasizing the need for careful monitoring and antibiotic stewardship to manage potential risks to both animal and human health. Full article

Bacterial skin infections are common in dogs and often secondary to underlying conditions like allergies or ectoparasite infestations. Untreated primary causes can lead to recurrent infections and an increased risk of antimicrobial resistance, including methicillin-resistant Staphylococcus pseudintermedius (MRSP), posing a substantial clinical challenge. Here, we analyzed 896 canine bacterial skin infection samples collected from the China Agricultural University Veterinary Teaching Hospital between 2018 and 2022. Species identification was confirmed by MALDI-TOF and 16S rRNA gene sequencing. Of the 896 samples, 722 (80.6%) yielded 1123 bacterial isolates, with Staphylococcus pseudintermedius (n = 421), Pseudomonas aeruginosa (n = 108), and Escherichia coli (n = 73) being the most prevalent. Antimicrobial susceptibility was evaluated using the broth microdilution method according to CLSI guidelines. Notably, resistance to florfenicol in S. pseudintermedius increased from 9.1% in 2018 to 20.0% in 2022, while resistance to ceftriaxone in E. coli rose from 30.0% to 72.7% over the same period. Among 305 reviewed cases, pyoderma (47.5%, 145/305) was the most common infection type, predominantly associated with S. pseudintermedius (n = 114), followed by otitis (25.6%, 78/305) primarily linked to P. aeruginosa (n = 24). Mixed infections occurred in 35.4% (108/305) of cases, with S. pseudintermedius as the most frequently isolated species in both single and mixed infections. The multivariable logistic regression model revealed that MRSP infections were correlated with a history of invasion (p <0.001) and prolonged disease duration (six months to less than one year: p = 0.005; one year or longer: p < 0.001). Core-genome SNP analysis showed that eight dogs were infected with identical S. pseudintermedius strains, in which one dog exhibited a shift from gentamicin susceptibility to resistance within nine days. Conversely, three dogs were infected by distinct S. pseudintermedius strains at two time points. To effectively manage MRSP infections and chronic skin infections in dogs, rigorous disinfection protocols in veterinary hospitals, control of disease duration, prevention of recurrent infections, and continuous monitoring of antibiotic resistance patterns are essential. Full article

The rising threat of antimicrobial resistance (AMR) is a global concern in both human and veterinary medicine, with multidrug-resistant (MDR) pathogens such as Staphylococcus aureus and Staphylococcus pseudintermedius presenting significant challenges. Background/Objectives: This study evaluates the effectiveness of amoxicillin against these MDR pathogens in canine isolates using pharmacokinetic and pharmacodynamic parameters. Methods: Minimum inhibitory concentration (MIC), minimum bactericidal concentration (MBC), and mutation prevention concentration (MPC) were assessed. Additionally, time-kill assays and post-antibiotic effect (PAE) assessments were performed. Epidemiological cutoff (ECOFF) values were established for both species to guide therapy. Results: S. aureus had a higher resistance rate (35.89%) than S. pseudintermedius (15.27%), with MIC50 values of 0.50 μg/mL and 0.25 μg/mL, respectively. The MPC analysis revealed that S. pseudintermedius required higher antibiotic concentrations (16.11 μg/mL) to prevent mutations compared to S. aureus (2.20 μg/mL). Time-kill assays indicated that higher amoxicillin dosages caused faster bacterial reduction. The PAE analysis showed extended post-treatment bacterial suppression at elevated doses, particularly against S. aureus. Conclusions: Species-specific amoxicillin dosing strategies are necessary due to differing resistance and susceptibility profiles between S. aureus and S. pseudintermedius. High-dose amoxicillin therapy is recommended to achieve optimal therapeutic outcomes for resistant SA, while slightly adjusted dosing can manage S. pseudintermedius infections. These findings provide essential insights for veterinary antimicrobial stewardship, underscoring the need for tailored therapeutic approaches to minimize AMR development while ensuring effective infection control. Full article

Background/Objectives: Infections in dogs caused by methicillin-resistant staphylococci (MRS) present limited treatment options. This study’s objective was to investigate the molecular epidemiology of Staphylococcus spp. cultured exclusively from clinical canine skin and ear samples in Queensland, Australia, using whole-genome sequencing (WGS). Methods: Forty-two Staphylococcus spp. isolated from clinical canine skin and ear samples, from an unknown number of dogs, were sourced from two veterinary diagnostic laboratories between January 2022 and May 2023. These isolates underwent matrix-assisted laser desorption ionisation– time of flight bacterial identification, minimum inhibitory concentration testing using Sensititre^TM plates and WGS. Phylogenetic trees and core genome multilocus sequence typing (cgMLST) minimum spanning trees (MSTs) were constructed. Results: The isolates included methicillin-resistant and -sensitive S. pseudintermedius (MRSP: 57.1%, 24/42; and MSSP: 19.1%, 8/42), methicillin-resistant and -sensitive S. coagulans (MRSC: 14.3%, 6/42; and MSSC: 2.4%, 1/42) and methicillin-resistant coagulase-negative staphylococci (MR-CoNS: 7.1%, 3/42). Thirty-nine isolates were included after WGS, where all MRS harboured the mecA gene. Eighteen sequence types (STs) were identified, including three novel MRSP and six novel MSSP STs. MRSP ST496-V-VII (23%; 9/39) and MRSP ST749-IV-(IVg) (12.8%; 5/39) were commonly isolated. Phylogenetic analysis of single nucleotide polymorphisms showed that MRSP, MRSC and MSSC were similar to globally isolated staphylococci from canine skin and ear infections. Using cgMLST MSTs, MRSP isolates were not closely related to global strains. Conclusions: Our findings revealed a genotypically diverse geographical distribution and phylogenetic relatedness of staphylococci cultured from clinical canine skin and ear samples across Queensland. This highlights the importance of ongoing surveillance to aid in evidence-based treatment decisions and antimicrobial stewardship. Full article

Antibiotic resistance in bacteria from companion animals poses significant public health risks. Prudent antibiotic use, particularly through pharmacokinetics/pharmacodynamics modeling, is crucial for minimizing resistance. We investigated the pharmacokinetics/pharmacodynamics of amoxicillin (AMX) against Staphylococcus pseudintermedius. A pharmacokinetic study was conducted on healthy dogs subcutaneously injected with a dose of 15 mg/kg AMX. The antibacterial efficacy of AMX was evaluated against a standard strain from animals (KCTC 3344) and clinical isolates from dogs (B-2, B-7, and B-8), with minimum inhibitory concentrations (MICs) of 0.25, 0.5, 64, and 16 μg/mL, respectively. The half-life of AMX was 7 h, allowing for extended drug efficacy. The time above MIC (%T $>$ MIC) values indicated that the AMX concentrations were maintained above MICs of the two susceptible strains (KCTC 3344 and B-2) for more than 80% of the time when dosed at a one-day interval, suggesting an effective treatment. The area under the curve over 24 h/MIC ratios confirmed the bacteriostatic, bactericidal, and bacterial eradication effects of AMX against S. pseudintermedius strains, except for B-7 (the most resistant strain). These results support improved clinical dosing strategies for AMX against S. pseudintermedius infections in dogs. Full article

Bacterial skin infections, particularly pyoderma and otitis externa, are widespread in dogs, primarily caused by Staphylococcus and Pseudomonas species. This study evaluates the prevalence and types of bacterial pathogens in affected dogs in South Korea using a meta-analytical approach. Following the PRISMA guidelines, five electronic databases were searched for relevant studies published between 1990 and 2024. Three researchers independently performed data extraction and quality assessment. A subgroup analysis explored the variability in pathogen prevalence across studies based on bacterial genus, bacterial species, publication year, sampling year, sampling location, infection type, diagnostic method, and sample size. Publication bias was evaluated using funnel plots and Egger’s regression test, with all analyses conducted using the R program. Of the 944 articles, 29 met the eligibility criteria. The pooled bacterial prevalence among infected dogs was 99.95% (95%CI: 99.85–100). Staphylococcus was the most prevalent genus (95.93%), followed by Pseudomonas (48.43%), Enterococcus (20.32%), and Escherichia (17.63%). The most common species were Staphylococcus pseudintermedius (78.89%), Staphylococcus intermedius (71.43%), and Pseudomonas aeruginosa (46.13%). This study underscores the need for comprehensive treatment strategies targeting Gram-negative and Gram-positive bacteria, emphasizing further research on antimicrobial resistance patterns and treatment efficacy to enhance canine health outcomes in South Korea. Full article

Introduction: Antimicrobial resistance (AMR) has surfaced as a critical challenge to public health on a global scale. The precise and swift identification of resistance to antimicrobial agents, along with timely and suitable antimicrobial therapy paired with effective stewardship practices, is crucial for managing the rise and dissemination of antimicrobial resistance. The objective of our investigation was to outline the antimicrobial resistance profile of Staphylococcus spp., a significant contributor to canine otitis, a prevalent condition in dogs, isolated in Western Romania. Methods and Materials: All data were collected from clinical cases of canine otitis externa which presented at the University Clinic of the Faculty of Veterinary Medicine in Timișoara/Romania. A clinical evaluation was conducted, from which era swabs are usually collected and sent for analysis at the laboratory. Laboratory analysis included the microbiological examination for identifying Staphylococcus spp. and determining antibiotic susceptibility phenotypes. Statistical analysis was implemented on all data that were collected. The ear swabs were processed with standard procedures for cultivating and identifying bacteria. The resulting subcultures were processed to determine the staphylococcal species on the GP ID Cards of the Vitek^® 2 automatic system. The antimicrobial susceptibility profiles were detected by the Vitek^® 2 system using an AST-GP80 card. These isolated Staphylococcus spp. strains were further processed by real-time PCR and PCR-RFLP. Results: Of all the auricular exudate samples analyzed, 76 were positive for Staphylococcus spp. (59.38%). Within these, in 82% of auricular samples, six distinct Staphylococcus spp. were identified (Staphylococcus (S.) pseudintermedius, S. intermedius, S. hyicus, S. delphiny, S. shleiferi, and S. aureus). Our data indicate that the PCR-RFLP assay is a practical approach to S. pseudintermedius identification, allowing for discrimination from the other Staphylococcus Intermedius Group (SIG) species and important staphylococcal pathogens of dogs. The highest frequency of resistant S. pseudintermedius isolates was detected against tetracycline (21/34; 61.76%; p-value 0.003), gentamicin (20/34; 58.82%), and kanamycin (20/34; 58.82%). Conclusions: These results are essential to guide the prudent use of antibiotics in veterinary medicine. They will also help design efficient control strategies and measure their effectiveness. Full article

Background/Objectives: Staphylococcus aureus and Staphylococcus pseudintermedius are major opportunistic pathogens in both humans and dogs. In pets, the dissemination of methicillin-resistant isolates (MRSA or MRSP) is problematic for the treatment of animals and is a public health issue due to their zoonotic potential. MRSA and MRSP may also harbor virulent genes that increase their dangerousness. This study aimed to assess the prevalence of (MR)SA and (MR)SP in healthy dogs and their owners in Algeria. Methods: Swabs were collected from various body sites of healthy dogs (n = 88) and from the nose of their owners (n = 38). Antimicrobial susceptibility testing was performed by antibiograms according to the disc diffusion method, and clonality was assessed using Pulsed-Field Gel Electrophoresis (PFGE). All methicillin-resistant isolates were short-read whole-genome sequenced using the Illumina technology. Results: 26 S. aureus and 17 S. pseudintermedius isolates were respectively collected from 13 dogs (13/88, 14.8%). No MRSP isolate was detected, while MRSA was found in six dogs (6.8%). Isolates belonged to ST1 (n = 3), ST 80 (n = 1), and ST 22 (n = 2, including the single-locus variant ST7118). All MRSA displayed the immune evasion cluster (IEC) type E. The ST80 isolate presented the Panton–Valentine toxin, and the ST22/ST7118 isolates carried the tst gene coding for the toxic shock syndrome toxin. Conclusions: The epidemiology of MRSA in healthy Algerian dogs mirrors the one in Algerian people. This poses a zoonotic and public health concern due to the virulence and resistance genes displayed by these isolates. Our results indicate the need for developing One Health strategies to avoid a large-scale dissemination of MRSA in Algerian dogs. Full article

Background/Objectives: Staphylococcus pseudintermedius is part of the normal microbiota in dogs. Since 2006, an increase in multidrug-resistant clones of methicillin-resistant S. pseudintermedius has been reported, as well as zoonotic transmission. Longitudinal investigations into clonal population structures, antibiotic resistance patterns, and the presence of resistance and virulence genes are important tools for gaining knowledge of the mechanisms behind the emergence of such clones. Methods: We investigated 87% of all non-repetitive MRSP isolates from dogs and cats in Sweden over a ten-year period (n = 356). All isolates were subjected to staphylococcal chromosomal cassette mec identification, whole-genome sequencing, multi-locus sequence typing, and analyses of genomic relatedness, as well as investigation of phenotypical resistance patterns and the presence of antibiotic resistance genes and virulence genes. Results: A considerable increase over time in the number of clonal lineages present was observed, indicating genomic diversification, and four clones became dominant: ST71, ST258, ST265, and ST551. In total, 96% of the isolates were multidrug-resistant. Statistically significant differences in resistance to several antibiotic classes between the four dominant clones were present. All isolates carried several virulence genes encoding factors associated with attachment, colonization, toxin synthesis, quorum sensing, antibiotic resistance, and immune evasion. Full article