Abstract
Background
Bacterial contamination of the Neonatal Intensive Care Unit (NICU) poses a significant risk for cross-transmission, potentially leading to infections in vulnerable neonates. Key pathogens involved in NICU-acquired infections such as Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. are collectively known as ESKAPE pathogens. They are known for their antibiotic resistance, posing challenges for treatment. This study aimed to investigate the prevalence and antibiotic resistance profiles of ESKAPE pathogens in the NICU at the Women and Newborn Hospital (WNH).
Methods
A total of 344 Samples were collected from different medical equipment, inanimate, animate surfaces and indoor air using standard microbiological methods. Antimicrobial susceptibility testing was then performed using the Kirby-Bauer method.
Results
Bacterial contamination rate was 323/344 (93.9%), with 83/323 (25.7%) of samples containing ESKAPE pathogens. Antimicrobial susceptibility varied among ESKAPE pathogens with a total of 75/83 (90%) of the ESKAPE isolates being multi-drug resistant (MDR). Gram-negative isolates exhibited high resistance to β-lactams, carbapenems, and fluoroquinolones, with susceptibility to aminoglycosides, while Gram-positive isolates showed resistance to β-lactams and macrolides but remained largely susceptible to linezolid, clindamycin, and vancomycin.
Conclusion
There was a high level of contamination with MDR ESKAPE pathogens in the NICU. This highlights the need for improved infection prevention and control measures as well as antimicrobial stewardship to prevent further resistance.
Keywords: Prevalence, Contamination, ESKAPE, Antibiotic resistance, Neonatal Intensive Care Unit
Introduction
The hospital environment is a reservoir for microorganisms, including MDR pathogens, which are implicated in healthcare-associated infections (HAIs) [1, 2]. Neonates in the NICU are particularly susceptible to infections due to their underdeveloped immune systems, compromised skin barriers, and critical medical conditions, which often necessitate invasive procedures [3]. This vulnerability is exacerbated in low- and middle-income countries (LMICs), where antibiotic resistance proportions are higher than in high-income settings [4].
The pathogens frequently associated with infections in the NICU include ESKAPE pathogens namely Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter sp. These pathogens are usually MDR and therefore are listed as priority pathogens against which new antibiotics are urgently needed [5]. Under the “Priority 1: Critical” category are Gram-negative pathogens which include A. baumannii, P. aeruginosa, K. pneumoniae, and Enterobacter sp. The “Priority 2: High” group includes the Gram-positive pathogens: E. faecium and S. aureus [6]. They exhibit extensive resistance to commonly used antibiotics in NICUs due to a variety of genetic mechanisms. This renders them resistant to a wide range of antibiotics, including cephalosporins, lipopeptides, macrolides, fluoroquinolones, tetracyclines, β-lactams, and carbapenems [7]. Drug resistant strains of S. aureus mainly Methicillin resistant S. aureus (MRSA), Vancomycin-resistant Enterococcus (VRE) and β-lactamase producing pathogens have proven to be health threats. They can survive in the hospital environment for a longer period and can be transferred from one individual to the other [8]. Evidence suggests that contaminated inanimate surfaces and medical equipment in NICUs play a role in harbouring these resistant strains [8]. This contamination poses risks to both patients and staff, particularly given the high mortality rates associated with infections caused by these pathogens and the limited treatment options available [9].
In Sub-Saharan Africa, studies have reported a high prevalence of bacterial contamination in NICUs, including 74.7% in Ethiopia [10] and 86.2% in Zimbabwe [11] with S. aureus and K. pneumoniae as the most frequently isolated pathogens in these regions. In Zambia, the WNH has been documented to have an increase in antimicrobial resistance (AMR) among bacteria from clinical samples [12]. Studies at WNH have also reported sepsis by MDR K. pneumoniae to be the leading cause of death in the NICU [13, 14] however none of these studies have looked at the collective burden of ESKAPE pathogens. This emphasizes the need for continuous assessment of this pathogen’s threat as well as investigation of other MDR ESKAPE pathogens. This study was therefore undertaken to determine the prevalence and antibiotic resistance patterns of ESKAPE pathogens isolated from equipment, inanimate, animate surfaces and indoor air in the NICU of the WNH in Lusaka, Zambia.
Methodology
Study area
This was a cross-sectional study conducted from April 2023 to July 2023. The study focused on determining prevalence and resistance patterns of ESKAPE pathogens isolated from the environment of NICU of the WNH in Lusaka, Zambia. The NICU in Lusaka typically features open bay areas, individual patient rooms, and a dedicated area for Kangaroo Mother Care. The unit averages approximately 3,500 admissions annually, with 75% of newborns admitted from the in-hospital labour and delivery ward. The remaining 25% are born at external facilities, including health centres and private hospitals across Lusaka, which lack advanced newborn care services [15]. According to administration records the NICU staff have a large caseload, often having more than 100 patients with only a 90-patient capacity and a patient to clinician ratio of 20:1. The detailed information regarding cleaning and disinfection of objects/instruments of NICU was obtained. Healthcare workers of the NICU follow standard hand washing protocols before and after examination of each baby. The floor is mopped twice a day with 0.5% chlorine and detergent solution. Non-invasive objects/instruments and surfaces like table tops are disinfected with 0.5% chlorine or STABISAN while Invasive instruments are disinfected with Cidex. Fumigation is scheduled every three months but is not consistently done.
Sampling procedure
A total of 344 samples were collected from nine different rooms of the NICU from medical equipment, inanimate and animate surfaces using purposive sampling. Animate sources included mothers’ hands (n = 20) and the skin of babies (n = 39) Skin surface sampling of babies was performed using sterile swabs moistened with sterile saline. The area swabbed on the babies was the trunk which is usually exposed and likely to be associated with colonization. Each site was gently but thoroughly swabbed using a standardized technique to ensure consistency across samples. Babies included in the study were selected based on their admission to the NICU for more than 48 h during the sampling period. Mothers were included based on the availability and willingness to participate, particularly those whose neonates were also enrolled, to explore potential vertical or horizontal transmission. Samples from mothers included hand swabs, given the known role of hand contact in neonatal pathogen transmission. Inanimate surface (n = 141) and medical equipment (n = 135) samples were collected using sterile swabs moistened with sterile saline between 10:00 h and 10:30 h, following routine morning cleaning. Nine air samples were also collected from the different rooms using the settle plate method [16]. Inanimate surfaces included frequently touched but non-clinical contact points such as bedside tables, floors, books, bins, cabinet handles, benches, and chairs. Medical equipment sampling focused on devices such as incubators, infant warmers, suction machines, oxygen concentrators, infusion tips and pumps, phototherapy beds, fluid delivery tips, medicine trolleys, handwashing buckets, and tube stands. For flat surfaces, swabbing was performed over an approximate area of 10 cm² using horizontal and vertical strokes, while small or irregularly shaped equipment was swabbed thoroughly over the entire surface. Each sample was labelled with the swabbing site, date, and time. All samples were placed in Amies transport media and transported to the Microbiology Laboratory within two hours for analysis.
Culture and identification
Each sample was inoculated on three different culture media (Blood agar, Chocolate agar and MacConkey agar) and incubated at 37oC for 24 h. Open-plate air exposure sample (from indoor air) were incubated aerobically for 24 h at 37oC. Initially bacteria were assessed for their colony characteristics and Gram-stained smears. Identification of Gram-positive bacteria was based on catalase test, coagulase test, novobiocin and bacitracin susceptibility following standard bacteriological techniques. Identification of Gram-negative bacteria was based on their reaction on indole, citrate agar, triple sugar iron agar, lysine decarboxylase agar, oxidase, and motility medium. Suspected ESKAPE pathogens were further confirmed by Vitek-2 Compact (Biomerieux, Durham USA).
Antimicrobial susceptibility testing
Antimicrobial susceptibility testing (AST) was carried out on selected bacterial isolates using the Kirby-Bauer disk diffusion method on Mueller Hinton agar. Antimicrobial impregnated disks were placed using sterile forceps on the agar surface and incubated at 37o C for 24 h. The zone diameters were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) 2023 guideline as susceptible (S), intermediate (I) or resistant (R). Methicillin resistance among S. aureus was detected by cefoxitin (30 µg) disc diffusion method.
Screening for ESBL production in K. pnuemoniae
The criteria for screening of Klebsiella isolates for Extended-Spectrum Beta-Lactamse (ESBL) production was based on resistance to third generation cephalosporins during the initial AST procedure. Confirmation was performed according to the CLSI M100 guidelines using the combination disc method. The method uses the cephalosporin discs, cefotaxime and ceftazidime alone, and combination discs cefotaxime/clavulanic acid and ceftazidime/clavulanic acid. The interpretation of the results was based on the zone size of each cephalosporin alone, compared with the discs containing the combination of the cephalosporin and clavulanic acid. If the zone diameter of the disc with the combination for any or both cephalosporins was higher or equal to 5 mm (≥ 5 mm), the result was interpreted as positive for ESBL.
Data analysis
Data were imported and analysed using Statistical Package for Social Sciences (SPSS) software version 28.0. Descriptive statistics were done for all variables and summarized as frequencies and percentages. Tables and figures were used to present the results. To summarise the susceptibility profile of all the ESKAPE pathogens, a heatmap was created in Excel. To compare the positivity of the ESKAPE pathogens between mothers’ hands and babies, a 2 × 2 Chi-square was used to compute a probability value (P-value), which was considered statistically significant if less than 0.05.
Results
Bacterial growth and prevalence of ESKAPE pathogens from 344 surface swabs
Of the 344 surface swabs obtained from NICU, 323 (93.9%) had bacterial growth, while the remaining 21 (6.1%) swabs did not show any bacterial growth. The prevalence of ESKAPE pathogens was 83/344 (24.1%), with 240/344 (69.8%) being bacterial growth other than ESKAPE pathogens. Figure 1.
Fig. 1.
Results of culture of 344 surface swabs from NICU
The majority of the ESKAPE pathogens isolated was K. pneumoniae at 33/83 (39.8%), followed by A. baumannii 24/83 (29.0%), while the least isolated bacteria was P. aeruginosa 3/83 (3.6%). Figure 2.
Fig. 2.
Distribution of ESKAPE pathogens isolated from NICU, WNH
ESKAPE isolates were recovered from various surface types in the NICU, with the highest number obtained from medical equipment 34% (28/ 83). The most isolated pathogen was K. pneumoniae predominantly from medical equipment 40% (13/33) followed by A. baumannii with most isolates from animate surfaces 42% (10/24). Enterobacter spp., S. aureus, P. aeruginosa, and E. faecium were the least recovered, with variable distribution across surface types. Table 1.
Table 1.
Distribution of ESKAPE pathogens by surface type in the NICU (n = 83)
| ESKAPE Pathogen | Animate Surfaces (n = 24) |
Inanimate Surfaces (n = 25) |
Medical Equipment (n = 28) |
Indoor Air (n = 5) |
Total Isolates (n = 83) |
|---|---|---|---|---|---|
| Enterobacter spp. | 1 (4.2%) | 4 (16.0%) | 1 (3.6%) | 1 (20.0%) | 7 |
| Staphylococcus aureus | 2 (8.3%) | 2 (8.0%) | 1 (3.6%) | 1 (20.0%) | 6 |
| Klebsiella pneumoniae | 8 (33.3%) | 10 (40.0%) | 13 (46.4%) | 2 (40.0%) | 33 |
| Acinetobacter baumannii | 10 (41.7%) | 6 (24.0%) | 7 (25.0%) | 1 (20.0%) | 24 |
| Pseudomonas aeruginosa | 1 (4.2%) | 2 (8.0%) | 0 (0.0%) | 0 (0.0%) | 3 |
| Enterococcus faecium | 2 (8.3%) | 1 (4.0%) | 6 (21.4%) | 0 (0.0%) | 9 |
ESKAPE pathogens were compared between mothers and babies, The percentage of positive and negative samples for ESKAPE pathogens isolated from two different sources: mothers’ hands (n = 20) and babies (n = 39) showed that there was a higher positivity rate of ESKAPE pathogens from mothers’ hands 12/20 (60%) compared to babies 17/39 (44%). Figure 3.
Fig. 3.
Relationship in terms of ESKAPE pathogens’ positivity between mother’s hands and babies
Antibiotic resistance profiles of ESKAPE pathogens
There was high resistance of Enterobacter spp. to aztreonam 6/7 (86.7%) and meropenem 6/7 (86.7%). K. pneumoniae exhibited significant resistance to cotrimoxazole 33/33 (100%), cefepime 32/33 (97.0%), aztreonam 30/33 (90.9%) and ceftazidime 31/33 (94.0%). Importantly, most of the K. pneumoniae strains were resistant to meropenem. A. baumannii was highly resistant to aztreonam 24/24 (100%), ceftriaxone 17/24 (70.8%), ceftazidime 22/24 (91.7%), and cefepime 16/24 (66.7%). P. aeruginosa displayed resistance to aztreonam 2/3 (66.7%) and meropenem 2/3 (66.7%). Table 2.
Table 2.
Antibiotic resistant patterns of Gram-negative ESKAPE pathogens
| Antibiotics | Enterobacter sp. (n = 7) | K. pneumoniae (n = 33) | A. baumannii (n = 24) | P. aeruginosa (n = 3) |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | |
| Amikacin | 3 (42.9%) | 2 (6.1%) | 9 (37.5%) | 1 (33.3%) |
| Ampicillin/sulbactam | 5 (71.4%) | 28 (84.8%) | 8 (33,3%) | 0 (0%) |
| Aztreonam | 6 (86.7%) | 30 (90.9%) | 24 (100%) | 2 (66.7%) |
| Ciprofloxacin | 3 (42.9%) | 2 (6.1%) | 1 (4.2%) | 1 (33.3%) |
| Ceftriaxone | 5 (71.4%) | 32 (97.0%) | 17 (70.8%) | NT |
| Ceftazidime | 5 (71.4%) | 31 (94.0%) | 22 (91.7%) | 1 (33.3%) |
| Cotrimoxazole | 5 (71.4%) | 33 (100%) | 7 (29.2%) | NT |
| Cefepime | 3 (42.9%) | 32 (97.0%) | 16 (66.7%) | 1 (33.3%) |
| Gentamicin | 1 (14.3%) | 11 (33.3%) | 2 (8.2%) | 1 (33.3%) |
| Meropenem | 6 (86.7%) | 29 (87.9%) | 15 (62.5%) | 2 (66.7%) |
| Piperacillin/Tazobactam | 0 (0%) | 12 (36.4%) | 9 (37.5%) | 0 (0%) |
| Tetracycline | NT | 1 (3%) | 10 (41.7%) | NT |
NT = Antibiotic not tested
S. aureus exhibited high resistance to cefoxitin 5/7 (71.4%) and 5/7 (71.4%) resistance to penicillin. E. faecium exhibited high resistance to linezolid 8/9 (88.9%), tetracycline 8/9 (88.9%), penicillin 7/9 (77.8%), erythromycin 7/9 (77.8%), ciprofloxacin 7/9 (77.8%) and chloramphenicol 6/9 (77.7%). Table 3.
Table 3.
Antibiotic resistant patterns of Gram-positive ESKAPE pathogens
| Antibiotics | S. aureus (n = 7) | E. faecium (n = 9) |
|---|---|---|
| n (%) | n (%) | |
| Penicillin G | 5 (71.4%) | 7 (77.8%) |
| Ampicillin | NT | 1 (11.1%) |
| Cefoxitin | 5 (71.4%) | NT |
| Erythromycin | 3 (42.9%) | 7 (77.8%) |
| Chloramphenicol | 1 (14.3%) | 6 (77.7%) |
| Nitrofurantoin | NT | 7 (77.8%) |
| Linezolid | 1 (14.3%) | 8 (88.9%) |
| Ciprofloxacin | 2 (28.6%) | 7 (77.8%) |
| Vancomycin | NT | 3 (33.3%) |
| Cotrimoxazole | 5(71.4%) | NT |
| Tetracycline | 1 (14.3%) | 8 (88.9%) |
| Gentamicin | 0 (0%) | NT |
| Clindamycin | 4 (57.1%) | NT |
NT = Antibiotic not tested
Enterobacter sp. were susceptible to piperacillin/tazobactam 4/7 (57.7%), and gentamicin 5/7 (71.4%). K. pneumoniae demonstrated high susceptibility to amikacin 29/33 (87.9%) and gentamicin 20/33 (60.6%). A. baumannii showed high susceptibility to gentamicin 22/24 (91.7%) and amikacin 12/24 (50%). P. aeruginosa exhibited susceptibility to ampicillin/sulbactam, ciprofloxacin, ceftazidime, and gentamicin 2/3(both 66.7%). S. aureus was highly susceptible to gentamicin 7/7 (100%), linezolid 6/7 (85.7%), clindamycin 6/7 (85.7%), and chloramphenicol 6/7 (85.7%). E. faecium showed moderate susceptibility to vancomycin 5/9 (55.6%). Figure 4.
Fig. 4.
Antimicrobial susceptibility patterns of the 83 ESKAPE pathogens
Discussion
The NICU exhibited a high level of bacterial contamination across various surfaces indicating a potential risk of pathogen transmission to neonates. Neonates are immunologically vulnerable therefore such high contamination rates elevate the risk of HAIs, potentially leading to life-threatening complications such as sepsis, pneumonia, and meningitis [17]. The overall contamination rate in this study was 94%, closely aligning with the 95% reported by Ashur [18] in Libya, however this rate is notably higher than those reported in other settings [2, 10, 11]. These differences may be attributed to variations in the types of surfaces sampled, disinfection methods, types of disinfectants used, and hygiene practices [19]. The elevated contamination rate observed in this study could also be influenced by the high patient load in the NICU, which results in increased foot traffic from mothers and healthcare workers.
The predominant bacterial isolate in this study was K. pneumoniae which is in contrast to other studies that have reported S. aureus as the most frequently isolated pathogen in their NICUs [19, 20]. This suggests that bacterial prevalence can vary across hospital environments and geographic regions. A comparison of ESKAPE pathogen isolation between mothers’ hands and babies showed no significant association between the positivity on the mother’s hands and the babies. There was a higher positivity rate among mothers (60%) than babies (44%) suggesting a potential role of maternal hand contamination in the transmission of ESKAPE pathogens to neonates. This however can only be verified by more specific tests such as molecular characterization and sequencing. The relatively elevated positivity among maternal hand samples highlights the need for strengthened hand hygiene practices to reduce the risk of nosocomial transmission in neonatal care settings. The colonization of neonatal skin by MDR bacteria poses a direct threat of invasive infections, especially in preterm neonates with immature immune systems. Furthermore, K. pneumoniae and A. baumannii were also isolated from items intended to be sterile, such as feeding cups and oxygen concentrator water [21]. This may be attributable to suboptimal disinfection methods or reduced effectiveness of hand disinfectants due to microbial resistance [22–24]. Additionally, the biofilm-forming capacity of A. baumannii enhances its resilience to disinfectants, further complicating eradication efforts and posing a persistent threat to neonatal health [25].
Antimicrobial susceptibility testing revealed a troubling pattern of resistance among ESKAPE pathogens. A large proportion of isolates showed resistance to meropenem which is a last-resort antibiotic. Despite this, many meropenem-resistant isolates remained susceptible to aminoglycosides, such as gentamicin and amikacin which is in alignment with findings from other NICUs [20, 26]. These results indicate that aminoglycosides may still have therapeutic value in NICU settings, although their use must be carefully monitored due to the potential for nephrotoxicity and ototoxicity in neonates [27]. The isolates of S. aureus exhibited high resistance to penicillin and cefoxitin, indicating a significant presence of methicillin-resistant S. aureus (MRSA), likely harbouring the mecA gene [27]. These MRSA strains were mostly isolated from baby skin presenting a serious risk of cross-transmission for babies sharing a cot due to overcrowding. MRSA can cause severe infections in neonates, including bloodstream infections, pneumonia, and soft tissue infections, all of which contribute to increased morbidity and mortality [28]. The resistance profile of E. faecium was particularly concerning, with 88.9% of isolates resistant to linezolid an agent used for treating Gram-positive MDR infections. Linezolid is widely regarded as a last-resort antibiotic for the treatment of MDR Gram-positive bacterial infections. Therefore, the high prevalence of resistance to this critical agent significantly narrows the available therapeutic options for managing E. faecium infections.
Among Gram-negative organisms in this study, aminoglycosides remained effective against A. baumannii and Enterobacter spp. but were resistant to several β-lactam agents which is consistent with global trends [29, 30]. Widespread resistance to aztreonam, piperacillin, and third generation cephalosporins observed in this study indicated likely production of ESBLs, as previously reported at this institution [12]. Although P. aeruginosa was least isolated, it showed resistance to piperacillin-tazobactam and meropenem which are common empiric choices. Fortunately, susceptibility to ciprofloxacin and gentamicin was retained, unlike in other studies where ciprofloxacin resistance was high [31, 32]. K. pneumoniae isolates were highly resistant to third generation cephalosporins which was confirmed by the screening for ESBL production. They were also highly resistant to meropenem, suggesting the presence of carbapenemase producing strains. A study from south Africa reported similar results of K. pneumoniae isolates being ESBL positive however they reported more than 90% sensitivity against carbapenems [33]. The findings in this study echo the growing global prevalence of hypervirulent carbapenem-resistant K. pneumoniae, which can cause severe infections not only in immunocompromised patients but also in healthy individuals [34]. Most isolates remained susceptible to gentamicin and amikacin, an observation that holds significant clinical value. These results are similar to other studies that have reported effectiveness of aminoglycosides against K. pneumoniae [30, 35].
In suspected neonatal sepsis cases, the empiric antibiotic regimen in the NICU at WNH comprises amikacin combined with piperacillin-tazobactam, based on historical susceptibility trends. Blood cultures are not routinely performed before the initiation of antibiotics which prevents clinicians from making informed, targeted treatment decisions. This not only risks poor outcomes but also drives the emergence of further resistance through inappropriate antibiotic use. Our study findings therefore raise concern over the efficacy of current empiric therapy as significant proportion of Gram-negative isolates were resistant to piperacillin-tazobactam and amikacin. The current findings have provided baseline information of ESAKPE pathogens in the NICU at WNH for future research. The results have also contributed to the growing body of evidence calling for integrated NICU surveillance programs that include colonization screening, environmental monitoring, and real-time antimicrobial stewardship. In LMIC settings, where laboratory capacity is often limited, such targeted surveillance can help guide empiric therapy, prevent outbreaks, and inform infection control interventions.
Conclusion
There was a high level of contamination by ESKAPE pathogens across various surfaces in the NICU suggesting significant gaps in existing IPC measures. Antimicrobial susceptibility testing showed alarming MDR in most the ESKAPE isolates which compromises therapeutic options for the vulnerable neonatal population. These findings highlight the urgent need to reinforce infection control protocols, implement routine environmental surveillance, and strengthen antimicrobial stewardship practices. Targeted interventions are essential to reduce the burden of contamination and limit the spread of resistant pathogens in critical care settings.
Limitations of the study
This study was conducted in a single tertiary hospital NICU over a short duration, which may not capture broader epidemiological patterns or seasonal variations in antimicrobial resistance. The molecular identification and characterization of the ESKAPE pathogens was not done. Additionally, the study did not compare environmental isolates with clinical blood culture data, limiting insights into the clinical relevance and transmission dynamics of the detected pathogens.
Acknowledgements
Many thanks to the staff members of the NICU of the WNH, mothers who participated in the research and the Bacteriology Laboratory staff for all their valuable support. Gratitude also goes to the Ministry of Science and technology for the financial support.
Author contributions
SN, as a principal investigator, designed the study, collected and processed the specimens, and drafted the manuscript. AS contributed to the design of the study, data analysis and refined the manuscript. MS, JM and GM contributed to design of the study, formulated the objectives and refined the manuscript. All authors have read and approved the final manuscript.
Funding
This study was partially funded by the Ministry of Science and Technology.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the University of Zambia Biomedical research ethics committee (UNZABREC) (REF. 3175 − 2022) and the National Health research authority (NHRA) (REF: NHRA0000004/22/11/2022). Informed consent was obtained from all participating mothers prior to swabbing their hands as well as their baby’s skin.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.