Nosocomial outbreak by imipenem-resistant metallo-β-lactamase-producing Pseudomonas aeruginosa in an adult intensive care unit in a Brazilian teaching hospital | Enfermedades Infecciosas y Microbiología Clínica

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Lirios Juliá, Javier Colomina, Victoria Domínguez, Nieves Orta, Antonio Guerrero" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M. Lirios" "apellidos" => "Juliá" ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Colomina" ] 2 => array:2 [ "nombre" => "Victoria" "apellidos" => "Domínguez" ] 3 => array:2 [ "nombre" => "Nieves" "apellidos" => "Orta" ] 4 => array:2 [ "nombre" => "Antonio" "apellidos" => "Guerrero" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X09001207?idApp=UINPBA00004N" "url" => "/0213005X/0000002700000005/v1_201305090137/S0213005X09001207/v1_201305090137/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Nosocomial outbreak by imipenem-resistant metallo-β-lactamase-producing Pseudomonas aeruginosa in an adult intensive care unit in a Brazilian teaching hospital" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "269" "paginaFinal" => "274" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Renata Cristina Cezário, Lea Duarte De Morais, Joseane Cristina Ferreira, Rogério M. Costa-Pinto, Ana Lúcia da Costa Darini, Paulo P. Gontijo-Filho" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Renata Cristina" "apellidos" => "Cezário" "email" => array:1 [ 0 => "cezariorenata@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Lea" "apellidos" => "Duarte De Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff2" ] ] ] 2 => array:3 [ "nombre" => "Joseane Cristina" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff3" ] ] ] 3 => array:4 [ "Iniciales" => "R.M." "nombre" => "Rogério M." "apellidos" => "Costa-Pinto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff4" ] ] ] 4 => array:4 [ "Iniciales" => "A.L." "nombre" => "Ana Lúcia" "apellidos" => "da Costa Darini" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff4" ] ] ] 5 => array:3 [ "nombre" => "Paulo P." "apellidos" => "Gontijo-Filho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff1" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Area Immunology, Parasitology and Microbiology at Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil" "etiqueta" => "a" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Microbiology Laboratory of Hospital de Clinicas da Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil" "etiqueta" => "b" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Faculty of Mathematics, Statistical and Biometric Studies at Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil" "etiqueta" => "c" "identificador" => "aff3" ] 3 => array:3 [ "entidad" => "Clinical, Toxicologic and Bromatologic Analyses of Pharmaceutical Sciences at Universidade de São Paulo/USP, Ribeirão Preto, Brazil" "etiqueta" => "d" "identificador" => "aff4" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Autor para correspondencia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote nosocomial causado por Pseudomonas aeruginosa resistente a imipenem productora de metalo-β-lactamasa en unidad de cuidados intensivos para adultos de un hospital universitario brasileño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2791 "Ancho" => 2916 "Tamanyo" => 521284 ] ] "descripcion" => array:1 [ "en" => "Schematic representation of temporal and spatial relationships among patients infected with imipenem-resistant Pseudomonas aeruginosa during the study period. The arrows represent referral of patients from other hospitals to the ICU in Uberlandia Federal University Hospital, black sections indicate the time the patient was another ward, sections with hatched lines indicate time the patient was in the ICU and infected by imipenem-resistant P. aeruginosa, and crosses indicate death of the patient." ] ] ] "textoCompleto" => "IntroductionPseudomonas aeruginosa is an opportunistic pathogen that can cause severe invasive disease in critically ill and immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib1">1</a> This microorganism is an important cause of nosocomial infections, including pneumonia, wound infections, bacteremia, and urinary tract infection,<a class="elsevierStyleCrossRefs" href="#bib2">2,3</a>P. aeruginosa is frequent cause of ventilator-associated pneumonia in intensive care units (ICUs), the associated risk factors being mechanical ventilation lasting longer than 7 days, severity of the underlying condition, and previous antibiotic treatment, surgery, or immunosuppression.<a class="elsevierStyleCrossRefs" href="#bib3">3,4</a>P. aeruginosa is a uniquely problematic microorganism because of a combination of inherent resistance to many drug classes and an ability to acquire resistance to all relevant treatments.<a class="elsevierStyleCrossRef" href="#bib5">5</a> Thus, carbapenems remain one of the best therapy options, although their use is threatened by the emergence of carbapenem-hydrolyzing, enzyme-producing strains and dissemination of multidrug-resistant clones. One reported outbreak of P. aeruginosa was only susceptible to polymyxin.<a class="elsevierStyleCrossRefs" href="#bib6">6,7</a> In Brazilian hospitals, P. aeruginosa is a leading cause of nosocomial infection and the first cause of nosocomial pneumonia, notably in ICUs.<a class="elsevierStyleCrossRefs" href="#bib8">8–10</a>This study describes a nosocomial outbreak of imipenem-resistant, metallo-β-lactamase-producing P. aeruginosa with horizontal transmission in patients hospitalized in a mixed ICU.MethodsHospitalThe Uberlândia University Hospital is a 500-bed, tertiary-care teaching hospital in the city of Uberlândia, Minas Gerais State, Brazil, with a 15-bed, mixed (surgical-clinical) adult ICU.Study designFrom November 2003 to June 2005, a case-control study was carried out to investigate an imipenem-resistant P. aeruginosa nosocomial outbreak, affecting 47 patients.The index case was a 77-year-old woman with a diagnosis of pulmonary thromboembolism, who had received cefepime, ceftriaxone, and ampicillin antibiotic treatment in the ICU of another Uberlandia hospital in November 2003. She was referred to the ICU of the university hospital with a clinical diagnosis of respiratory failure and acute abdomen. Forty-eight hours after starting mechanical ventilation, ventilator-associated pneumonia due to P. aeruginosa resistant to imipenem and other antimicrobial classes was detected (isolate 1). The patient remained in the unit for approximately 3 weeks. She received imipenem treatment for 24 hours, and was then switched to polymyxin B® for 30 days’ time; despite this treatment, she died.The risk factors associated with infection by imipenem-resistant P. aeruginosa (IRPa) were evaluated in a case-control study. Cases were defined as patients for whom culture had identified at least one IRPa strain (n=47). For each case, 2 or 3 controls were selected (n=122), defined as patients without IRPa infection, whose hospital stay coincided the closest in time with that of the infected patient. Only the first isolate per patient was considered for the analysis. During the study period, contamination of the health staff's hands (23), patients hospitalized during this period (86), and the surfaces in the ICU near the patients (mechanical ventilation unit, headboard, sinks) was investigated. The Institutional Ethics Committee gave their approval to conduct the study (CEP no186/2005).Data collectionData for each patient were collected from the medical charts. The following variables were analyzed: age, sex, duration of ICU stay, comorbid conditions (diabetes mellitus, AIDS, renal failure, immunosuppression, cardiovascular disease), surgery, invasive device use (mechanical ventilation, central venous catheter, nasogastric tube) and prior use of antimicrobial drugs.Identification and susceptibility testing proceduresBacterial strains were identified by conventional biochemical tests, as described elsewhere.<a class="elsevierStyleCrossRef" href="#bib11">11</a> Susceptibility testing was performed by agar diffusion with the following antimicrobials agents (CECON®): aztreonam (30μg), ciprofloxacin (5μg), cefepime (30μg), imipenem (10μg), meropenem (10μg), ceftazidime (30μg), gentamicin (10μg), piperacillin/tazobactam (100/10μg), and polymyxin B (300U); the interpretative criteria used were those described in the CLSI (formerly NCCLS) guidelines.<a class="elsevierStyleCrossRef" href="#bib12">12</a> Quality control was conducted using P. aeruginosa ATCC 27853. P. aeruginosa was defined as being multidrug-resistant when the organism was resistant to imipenem/meropenem and 2 or more of the other antimicrobial classes studied, except polymyxin.Phenotypic metallo-β-lactamase productionAll strains resistant to ceftazidime and/or imipenem were screened for metallo-β-lactamase (MBL) production by the disk approximation test, using filter disks with ceftazidime (30μg) and imipenem (10μg) at 25mm or 10mm equidistant, respectively, and disks containing the following inhibitors: 2μL of undiluted 2-mercaptopropionic acid (2-MPA) solution (Aldrich Chemical Co, Milwaukee, USA) or 5μL of EDTA 500mM solution, as described by Arakawa.<a class="elsevierStyleCrossRef" href="#bib13">13</a> The positive control strain was an IMP-1-producing P. aeruginosa (PSA 319).<a class="elsevierStyleCrossRef" href="#bib14">14</a>Detection of the bla geneBecause of cost constraints, 15 MBL-positive isolates were selected as representative strains for the detection of genes encoding Ambler class B β-lactamase of the VIM, IMP, or SPM type by PCR using the following specific primers (reading 5′-3′): vim forward, GTCTATTTGACCGCGTC, vim reverse; CTACTCAACGACTGAGCG; imp forward, ATGAGCAAGTTATCTGTATTC, imp reverse: GTCGCAACGACTGTGTAG and spm reverse: TCGCCGTGTCCAGGTATAAC, spm forward: CCTACAATCTAACGGCGACC. The cycling parameters were 95°C for 5min, followed by 30 denaturation cycles at 95°C for 1min, annealing at 40°C for 1min, and extension at 68°C for 1min. PCR products were visualized by electrophoresis on 0.8% agarose gels stained with 1% ethidium bromide.<a class="elsevierStyleCrossRefs" href="#bib14">14,15</a>Genotyping by pulsed-field gel electrophoresisAmong 47 IRPa isolates, 15 randomly selected isolates with a positive MBL-producing phenotype were typed using pulsed-field gel electrophoresis (PFGE), as described by Denton et al,<a class="elsevierStyleCrossRef" href="#bib16">16</a> with modifications. Each plug was digested with 30U of SpeI restriction endonuclease (Invitrogen, Carlsbad, CA) at 37°C for 12h. Briefly, electrophoresis was performed by a 1% PFGE agarose gel run on the Gene Navigator (Pharmacia, Amersham Biociences) instrument at 164V for 20.1h, at 14°C. The equipment was adjusted for a pulse of 5s for 20h and 15s for 0.1h. Band patterns were visualized by ethidium bromide staining and ultraviolet transillumination. Cloning was evaluated according to the Tenover criteria,<a class="elsevierStyleCrossRef" href="#bib17">17</a> based on visual comparisons of the band patterns of samples run together in the same gel. Genetic similarities in samples were analyzed with a multivariate statistical package (MVSP 3.0).Statistical analysisCategorical variables were assessed with the chi-square test and Fisher's exact test; significance was set at a P value of ⩽0.05. Odds ratios and 95% confidence intervals were calculated with Epi-Info software, version 5.0. Variables were selected by forward logistic regression for the multivariate analysis.ResultsFollowing the index case, 46 additional cases of hospital-acquired infection were documented, including mechanical ventilation-associated pneumonia (41), bloodstream infection (3), surgical wound infection (1) and urinary tract infection (1) caused by Pseudomonas aeruginosa resistant to imipenem and other antimicrobial agents, including cephalosporins, aminoglycosides, and fluoroquinolones (data not shown).<a class="elsevierStyleCrossRef" href="#fig1">Fig. 1</a> shows the mortality data and the temporal/spatial relationships (ICU stay) among the 47 patients, which provides evidence of cross-transmission of IRPa.<elsevierMultimedia ident="fig1"></elsevierMultimedia>During the scrutiny for contamination, P. aeruginosa was not detected on culture of samples from the hands of 23 professionals, although initially this was suspected as the route by which the microorganism had been disseminated. However, P. aeruginosa was found colonizing 15/86 (17.4%) of the patients examined and on surfaces located near the patients, including the mechanical ventilation nebulizer in 10/86 (11.6%) and the headboard of the bed in 3/86 (3.5%), but not the sinks.The majority of imipenem/ceftazidime-resistant P. aeruginosa strains in infected patients (33/43; 76.7%) had an MBL-positive phenotype, with no differences in detection between mercaptopropionic acid or EDTA (<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>). In the contamination scrutiny, 17.8% (5/28) of P. aeruginosa imipenem/ceftazidime-resistant strains had an MBL-positive phenotype. Only 26.7% (4/15) of MBL-producing strains were positive for the blaSPM−1 gene. The blaVIM−2, bla IMP−1, and blaSPM genes were not found.<elsevierMultimedia ident="tbl1"></elsevierMultimedia>GenotypingTwo strains collected from the environment and strains from tracheal secretions were MBL-producers. A total of 15 strains were typed; however, 2 specimens remained undefined. Four clones and their subclones were found on PFGE, with a predominance of clone A, A1, A2 (61.5%), followed by B, B1 (23.1%), C and D (1 sample each), and 2 indeterminate results (<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>).<elsevierMultimedia ident="tbl2"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a> shows the univariate analysis. On multivariate analysis, age ⩾60 years (P⩽0.02; OR 2.4; 95% CI 1.10–5.49), use of mechanical ventilation (P⩽0.001; OR 7.2; 95% CI 2.74–19.10), presence of a tracheotomy (P⩽0.02; OR 4.01; CI 1.17–13.72), and carbapenem use (P<0.001, OR 5.7; 95% CI 2.31–10.08) were risk factors for acquiring imipenem-resistant P. aeruginosa infection<elsevierMultimedia ident="tbl3"></elsevierMultimedia>DiscussionThe presence of MBL-producing P. aeruginosa has been described in many hospitals around the world.<a class="elsevierStyleCrossRef" href="#bib18">18</a> Nonetheless, dissemination of an SPM-1 MBL-producing P. aeruginosa epidemic has been demonstrated only in hospitals of different Brazilian regions.<a class="elsevierStyleCrossRefs" href="#bib8">8,14,19</a> As compared to other studies carried out in Brazil, the presently reported nosocomial outbreak of imipenem-resistant P. aeruginosa infection involved the largest number of cases to date (47 patients) and was associated with 4 clones. This study is the first to include an expressive number (≈60%) of critical IRPa-infected patients who died within 30 days after the infection.Pseudomonas aeruginosa is a leading pathogen in mechanical ventilation-associated nosocomial pneumonia, with an associated mortality rate of 20% to 80%.<a class="elsevierStyleCrossRefs" href="#bib8">8,9,20</a> During the outbreak in our hospital, pneumonia was the predominant infection, accounting for more than two-thirds (85%) of the cases, followed by bloodstream infection and surgical wounds.The multivariate logistic regression analysis showed that patients with nosocomial IPRa infection were more likely to have been exposed to mechanical ventilation, and that tracheotomy and use of carbapenems were predisposing factors for the infection. These findings are consistent with those of other studies.<a class="elsevierStyleCrossRefs" href="#bib4">4,20–22</a>Although the advent of carbapenems in the 1980s heralded a new treatment option for serious bacterial infections, carbapenem resistance is now observed in Enterobacteriaceae and Acinetobacter spp., and is becoming commonplace in P. aeruginosa.<a class="elsevierStyleCrossRef" href="#bib18">18</a>P. aeruginosa possessing MBLs has been increasingly reported worldwide, mainly in ICUs and including Brazil,<a class="elsevierStyleCrossRefs" href="#bib14">14,18,19</a> but at rates comparatively lower than those found in our study (≈90%).These enzymes are clinically relevant because of their ability to hydrolyze most β-lactams, including carbapenems (but excluding aztreonam),<a class="elsevierStyleCrossRef" href="#bib18">18</a> and their association with mobile genetic elements, increasing the possibility of rapid spread.<a class="elsevierStyleCrossRefs" href="#bib19">19,23–25</a> In the Americas, 6 different MBLs have been described in P aeruginosa, including SPM-1, IMP-1, IMP-16, VIM-2, VIM-8 and VIM-11<a class="elsevierStyleCrossRef" href="#bib18">18</a> and three MBL types (SPM-1, VIM-2 and IMP-1) have been detected in Brazilian hospitals, with most strains expressing blaSPM−1, which is disseminated among our hospitals.<a class="elsevierStyleCrossRefs" href="#bib8">8,14,19,22</a> We found that MBL-producing strains accounted for a substantial number of cases (76.7%), and that the strains were clinically relevant, because 70.0% of the patients died. In contrast to the reported results of Sader et al,<a class="elsevierStyleCrossRef" href="#bib26">26</a> neither blaIMP−1 or blaVIM−1 genes were found in this study.The acquisition of resistant bacteria in hospitals may be a consequence of selective pressure exerted by the use of antibiotics and/or horizontal dissemination.<a class="elsevierStyleCrossRef" href="#bib27">27</a> Molecular typing of strains presenting the blaSPM−1 gene showed the presence of a single clone (A). In the present study, multidrug-resistant P. aeruginosa strains were clustered in two major genotypes; these showed coresistance to most of the antimicrobial agents tested. Multidrug resistance can be explained by the accumulation of several resistance mechanisms, including gene mutation, over-expression of efflux pumps, loss or modification of porins, and acquired extended-spectrum β-lactamases.<a class="elsevierStyleCrossRef" href="#bib28">28</a> This suggests that the selective pressure of previous antimicrobial use in the unit contributed to the emergence of resistant clones.Both the SPM and non-SPM-infected patients were clustered for 18 months in a single unit, with overlapping during their hospitalization. These data suggest that horizontal transmission between these patients may have played a role in the dissemination of the infection. Clonal dissemination was detected within and between intensive care units in São Paulo (4) and Brasilia,<a class="elsevierStyleCrossRef" href="#bib10">10</a> but with unrelated strains recovered from one of them. These data differ from those of Pellegrino et al<a class="elsevierStyleCrossRef" href="#bib29">29</a> who reported clonal dissemination between private and public institutions in Rio de Janeiro, in which both presented an apparently endemic background.Detection of clonal dissemination usually indicates inadequate nosocomial infection control practice.<a class="elsevierStyleCrossRef" href="#bib10">10</a> This outbreak of P. aeruginosa infection was probably linked to transmission of the microorganism via the hands of healthcare workers. We did not identify hand carriage among the workers examined, but a spatial/temporal relationship was seen among the cases in our unit, and low adherence (23%) to proper hand washing<a class="elsevierStyleCrossRef" href="#bib30">30</a> practice was detected in a recent study.In conclusion, to our knowledge, this is the first study to conduct an analysis using both classical and molecular techniques of an outbreak of infection associated with a highly prevalent MBL-producing P. aeruginosa, including mainly blaSPM−1 strains clustered in 2 major genotype, resulting in a significant increase in mortality of elderly patients and in previous use of antibiotics. The clonal dissemination among patients in our unit indicates problems in nosocomial infection control practice, likely associated with low adherence to hand hygiene, and selective pressure that provides resistant strains with an advantage over their susceptible ancestors." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres149937" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec137868" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres149936" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec137867" "titulo" => "Palabras clave" ] 4 => array:1 [ "titulo" => "Introduction" ] 5 => array:2 [ "titulo" => "Methods" "secciones" => array:8 [ 0 => array:1 [ "titulo" => "Hospital" ] 1 => array:1 [ "titulo" => "Study design" ] 2 => array:1 [ "titulo" => "Data collection" ] 3 => array:1 [ "titulo" => "Identification and susceptibility testing procedures" ] 4 => array:1 [ "titulo" => "Phenotypic metallo-β-lactamase production" ] 5 => array:1 [ "titulo" => "Detection of the bla gene" ] 6 => array:1 [ "titulo" => "Genotyping by pulsed-field gel electrophoresis" ] 7 => array:1 [ "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "titulo" => "Results" "secciones" => array:1 [ 0 => array:1 [ "titulo" => "Genotyping" ] ] ] 7 => array:1 [ "titulo" => "Discussion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2008-01-25" "fechaAceptado" => "2008-09-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec137868" "palabras" => array:4 [ 0 => "Nosocomial outbreak" 1 => "Imipenem-resistant P. aeruginosa" 2 => "Metallo-β-lactamase" 3 => "Intensive care unit" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec137867" "palabras" => array:4 [ 0 => "Brote nosocomiales" 1 => "Pseudomonas aeruginosa resistente la imipenem" 2 => "Metallo-β-lactamase" 3 => "Unidad de cuidados intensivos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo describe an outbreak of imipenem-resistant metallo-β-lactamase-producing Pseudomonas aeruginosa, enzyme type bla, by horizontal transmission in patients admitted to a mixed adult ICU. MethodsA case-control study was carried out, including 47 patients (cases) and 122 patients (control) admitted to the mixed ICU of a university hospital in Minas Gerais, Brazil from November 2003 to July 2005. The infection site, risk factors, mortality, antibiotic susceptibility, metallo-β-lactamase (MBL) production, enzyme type, and clonal diversity were analyzed. ResultsA temporal/spatial relationship was detected in most patients (94%), overall mortality was 55.3%, and pneumonia was the predominant infection (85%). The majority of isolates (95%) were resistant to imipenem and other antibiotics, except for polymyxin, and showed MBL production (76.7%). Only bla SPM-1 (33%) was identified in the 15 specimens analyzed. In addition, 4 clones were identified, with a predominance of clone A (61.5%) and B (23.1%). On multivariate analysis, advanced age, mechanical ventilation, tracheostomy, and previous imipenem use were significant risk factors for imipenem-resistant P. aeruginosa infection. ConclusionsClonal dissemination of MBL-producing P. aeruginosa strains with a spatial/temporal relationship disclosed problems in the practice of hospital infection control, low adherence to hand hygiene, and empirical antibiotic use." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoDescribir un brote causado por Pseudomonas aeruginosa resistente a imipenem productora de metallo-β-lactamasa (MBL), tipo de bla de la enzima, con transmisión horizontal de la muestra epidémica en pacientes ingresados en una unidad de cuidados intensivos para adultos mixta. MétodosDurante el período comprendido entre noviembre de 2003 y julio de 2005, se realizó un estudio de casos y controles en el que se incluyó a 47 (casos) y 122 (control) pacientes en una unidad de cuidados intensivos para adultos mixta, de un hospital universitario de Uberlândia (Minas Gerais [Brasil]). Se analizaron los sitios de la infección, los factores de riesgo, la mortalidad total, la susceptibilidad a los antibióticos, la producción del tipo MBL, de la enzima y de la diversidad clonal. ResultadosEn la mayoría de los pacientes (94%) se detectó una relación temporal/espacial. El índice de mortalidad total fue del 55,3% y la neumonía era la infección predominante (85%). La mayoría de las cepas (95%) era resistente a imipenem y a otros antibióticos, excepto al polimixin y la producción de MBL (76,7%). Únicamente se identificó blaSPM−1 en los 15 especímenes analizados. Además, se detectaron 4 clones, con predominio del clon A (61,5%) y B (23,1%). En análisis multivariados, la vejez, la ventilación mecánica, la traqueotomía y el uso previo del carbapenem son factores de riesgo significativos para el desarrollo de la infección de P. aeruginosa resistente a imipenem. ConclusionesLa diseminación clonal de cepas de P. aeruginosa productora de MBL entre los pacientes con una relación temporal/espacial mostró problemas en el control de la infección del hospital, probablemente relacionado con una adherencia baja a la higiene de las manos y el uso empírico de los antibióticos." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2791 "Ancho" => 2916 "Tamanyo" => 521284 ] ] "descripcion" => array:1 [ "en" => "Schematic representation of temporal and spatial relationships among patients infected with imipenem-resistant Pseudomonas aeruginosa during the study period. The arrows represent referral of patients from other hospitals to the ICU in Uberlandia Federal University Hospital, black sections indicate the time the patient was another ward, sections with hatched lines indicate time the patient was in the ICU and infected by imipenem-resistant P. aeruginosa, and crosses indicate death of the patient." ] ] 1 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n/n IRPa (%)<a class="elsevierStyleCrossRef" href="#tblfn1ast">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MBL n (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilation-associated pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41/38 (93.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (87.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bloodstream infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/3 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (67.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical wound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/1 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urinary tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/1 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47/43 (94.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (76.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab243797.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn1ast" "etiqueta" => "*" "nota" => "Pseudomonas aeruginosa-infected patients/number of infections by IRPa." ] ] ] "descripcion" => array:1 [ "en" => "Infections by imipenem-resistant metallo-β-lactamase-producing Pseudomonas aeruginosa in ICU patients at Uberlandia Federal University Hospital" ] ] 2 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Isolation period \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Source (n isolates) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IRPa positive for blaSPM−1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">PGFE profile \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">December 2003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">March, April 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breath (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">January, February 2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intestine (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">March 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headboard (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND<a class="elsevierStyleCrossRef" href="#tblfn2ast">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">February 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">January 2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intestine (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">October 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May 2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">February 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intestine (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">January, November 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheal secretion (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab243798.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn2ast" "etiqueta" => "*" "nota" => "Not determined." ] ] ] "descripcion" => array:1 [ "en" => "Data on 15 metallo-β-lactamase-producing Pseudomonas aeruginosa isolates at the Uberlandia Federal University Hospital ICU" ] ] 3 => array:7 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "OR: odds ratio; 95% CI: 95% confidence interval." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Infected n=47 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Noninfected n=122 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P<a class="elsevierStyleCrossRef" href="#tblfn3ast">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female/Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/30 (36.2/63.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62/60 (50.8/49.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 (0.56–1.16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, y</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">⩾60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (23.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (41.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 (0.19–1.00) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Length of stay, days</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">⩾7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (93.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (16.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.14 (10.59–83.71) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbid conditions</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">03 (6.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">07 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.08 (0.41–2.89) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">03 (6.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (22.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.32 (0.11–0.95) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AIDS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">02 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">00 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.71 (2.89–4.76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">03 (6.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">03 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.85 (0.80–4.29) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive Devices</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central venous catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (63.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 (90.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.37 (0.24–0.57) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanical ventilation; MV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 (95.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 (65.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.92 (2.00–31.30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of MV, days</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">⩾7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 (85.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.10 (0.04–0.22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (25.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (18.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.381 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.36 (0.80–2.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (59.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (24.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.82 (1.73–4.60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antibiotic use</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">⩾2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (59.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (39.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.27 (1.08–4.79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cephalosporin (3rd/4th generation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (64.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (39.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.06 (1.23–3.44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Carbapenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (46.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">04 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.84 (3.27–7.16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quinolone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">05 (10.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">07 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.95 (0.95–4.02) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (27.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.01 (1.23–3.28) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab243799.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn3ast" "etiqueta" => "*" "nota" => "P⩽0,05." ] ] ] "descripcion" => array:1 [ "en" => "Univariate 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Nosocomial outbreak by imipenem-resistant metallo-β-lactamase-producing Pseudomonas aeruginosa in an adult intensive care unit in a Brazilian teaching hospital

Brote nosocomial causado por Pseudomonas aeruginosa resistente a imipenem productora de metalo-β-lactamasa en unidad de cuidados intensivos para adultos de un hospital universitario brasileño

Renata Cristina Cezárioa,

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cezariorenata@yahoo.com

Autor para correspondencia.

, Lea Duarte De Moraisb, Joseane Cristina Ferreirac, R.M.. Rogério M. Costa-Pintod, A.L.. Ana Lúcia da Costa Darinid, Paulo P. Gontijo-Filhoa

a Area Immunology, Parasitology and Microbiology at Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil

b Microbiology Laboratory of Hospital de Clinicas da Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil

c Faculty of Mathematics, Statistical and Biometric Studies at Universidade Federal de Uberlândia, Uberlândia-Minas Gerais, Brazil

d Clinical, Toxicologic and Bromatologic Analyses of Pharmaceutical Sciences at Universidade de São Paulo/USP, Ribeirão Preto, Brazil

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    "textoCompleto" => "<span class="elsevierStyleSections"><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> is an opportunistic pathogen that can cause severe invasive disease in critically ill and immunocompromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a> This microorganism is an important cause of nosocomial infections&#44; including pneumonia&#44; wound infections&#44; bacteremia&#44; and urinary tract infection&#44;<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2&#44;3</span></a><span class="elsevierStyleItalic">P&#46; aeruginosa</span> is frequent cause of ventilator-associated pneumonia in intensive care units &#40;ICUs&#41;&#44; the associated risk factors being mechanical ventilation lasting longer than 7 days&#44; severity of the underlying condition&#44; and previous antibiotic treatment&#44; surgery&#44; or immunosuppression&#46;<a class="elsevierStyleCrossRefs" href="#bib3"><span class="elsevierStyleSup">3&#44;4</span></a></p><p class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P&#46; aeruginosa</span> is a uniquely problematic microorganism because of a combination of inherent resistance to many drug classes and an ability to acquire resistance to all relevant treatments&#46;<a class="elsevierStyleCrossRef" href="#bib5"><span class="elsevierStyleSup">5</span></a> Thus&#44; carbapenems remain one of the best therapy options&#44; although their use is threatened by the emergence of carbapenem-hydrolyzing&#44; enzyme-producing strains and dissemination of multidrug-resistant clones&#46; One reported outbreak of <span class="elsevierStyleItalic">P&#46; aeruginosa</span> was only susceptible to polymyxin&#46;<a class="elsevierStyleCrossRefs" href="#bib6"><span class="elsevierStyleSup">6&#44;7</span></a> In Brazilian hospitals&#44; <span class="elsevierStyleItalic">P&#46; aeruginosa</span> is a leading cause of nosocomial infection and the first cause of nosocomial pneumonia&#44; notably in ICUs&#46;<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p class="elsevierStylePara elsevierViewall">This study describes a nosocomial outbreak of imipenem-resistant&#44; metallo-&#946;-lactamase-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span> with horizontal transmission in patients hospitalized in a mixed ICU&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hospital</span><p class="elsevierStylePara elsevierViewall">The Uberl&#226;ndia University Hospital is a 500-bed&#44; tertiary-care teaching hospital in the city of Uberl&#226;ndia&#44; Minas Gerais State&#44; Brazil&#44; with a 15-bed&#44; mixed &#40;surgical-clinical&#41; adult ICU&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study design</span><p class="elsevierStylePara elsevierViewall">From November 2003 to June 2005&#44; a case-control study was carried out to investigate an imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> nosocomial outbreak&#44; affecting 47 patients&#46;</p><p class="elsevierStylePara elsevierViewall">The index case was a 77-year-old woman with a diagnosis of pulmonary thromboembolism&#44; who had received cefepime&#44; ceftriaxone&#44; and ampicillin antibiotic treatment in the ICU of another Uberlandia hospital in November 2003&#46; She was referred to the ICU of the university hospital with a clinical diagnosis of respiratory failure and acute abdomen&#46; Forty-eight hours after starting mechanical ventilation&#44; ventilator-associated pneumonia due to <span class="elsevierStyleItalic">P&#46; aeruginosa</span> resistant to imipenem and other antimicrobial classes was detected &#40;isolate 1&#41;&#46; The patient remained in the unit for approximately 3 weeks&#46; She received imipenem treatment for 24 hours&#44; and was then switched to polymyxin B<span class="elsevierStyleSup">&#174;</span> for 30 days&#8217; time&#59; despite this treatment&#44; she died&#46;</p><p class="elsevierStylePara elsevierViewall">The risk factors associated with infection by imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> &#40;IRPa&#41; were evaluated in a case-control study&#46; Cases were defined as patients for whom culture had identified at least one IRPa strain &#40;n&#61;47&#41;&#46; For each case&#44; 2 or 3 controls were selected &#40;n&#61;122&#41;&#44; defined as patients without IRPa infection&#44; whose hospital stay coincided the closest in time with that of the infected patient&#46; Only the first isolate per patient was considered for the analysis&#46; During the study period&#44; contamination of the health staff&#39;s hands &#40;23&#41;&#44; patients hospitalized during this period &#40;86&#41;&#44; and the surfaces in the ICU near the patients &#40;mechanical ventilation unit&#44; headboard&#44; sinks&#41; was investigated&#46; The Institutional Ethics Committee gave their approval to conduct the study &#40;CEP n<span class="elsevierStyleSup">o</span>186&#47;2005&#41;&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data collection</span><p class="elsevierStylePara elsevierViewall">Data for each patient were collected from the medical charts&#46; The following variables were analyzed&#58; age&#44; sex&#44; duration of ICU stay&#44; comorbid conditions &#40;diabetes mellitus&#44; AIDS&#44; renal failure&#44; immunosuppression&#44; cardiovascular disease&#41;&#44; surgery&#44; invasive device use &#40;mechanical ventilation&#44; central venous catheter&#44; nasogastric tube&#41; and prior use of antimicrobial drugs&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Identification and susceptibility testing procedures</span><p class="elsevierStylePara elsevierViewall">Bacterial strains were identified by conventional biochemical tests&#44; as described elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib11"><span class="elsevierStyleSup">11</span></a> Susceptibility testing was performed by agar diffusion with the following antimicrobials agents &#40;CECON<span class="elsevierStyleSup">&#174;</span>&#41;&#58; aztreonam &#40;30<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; ciprofloxacin &#40;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; cefepime &#40;30<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; imipenem &#40;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; meropenem &#40;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; ceftazidime &#40;30<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; gentamicin &#40;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; piperacillin&#47;tazobactam &#40;100&#47;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; and polymyxin B &#40;300<span class="elsevierStyleHsp" style=""></span>U&#41;&#59; the interpretative criteria used were those described in the CLSI &#40;formerly NCCLS&#41; guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib12"><span class="elsevierStyleSup">12</span></a> Quality control was conducted using <span class="elsevierStyleItalic">P&#46; aeruginosa</span> ATCC 27853&#46; <span class="elsevierStyleItalic">P&#46; aeruginosa</span> was defined as being multidrug-resistant when the organism was resistant to imipenem&#47;meropenem and 2 or more of the other antimicrobial classes studied&#44; except polymyxin&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Phenotypic metallo-&#946;-lactamase production</span><p class="elsevierStylePara elsevierViewall">All strains resistant to ceftazidime and&#47;or imipenem were screened for metallo-&#946;-lactamase &#40;MBL&#41; production by the disk approximation test&#44; using filter disks with ceftazidime &#40;30<span class="elsevierStyleHsp" style=""></span>&#956;g&#41; and imipenem &#40;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#41; at 25<span class="elsevierStyleHsp" style=""></span>mm or 10<span class="elsevierStyleHsp" style=""></span>mm equidistant&#44; respectively&#44; and disks containing the following inhibitors&#58; 2<span class="elsevierStyleHsp" style=""></span>&#956;L of undiluted 2-mercaptopropionic acid &#40;2-MPA&#41; solution &#40;Aldrich Chemical Co&#44; Milwaukee&#44; USA&#41; or 5<span class="elsevierStyleHsp" style=""></span>&#956;L of EDTA 500<span class="elsevierStyleHsp" style=""></span>mM solution&#44; as described by Arakawa&#46;<a class="elsevierStyleCrossRef" href="#bib13"><span class="elsevierStyleSup">13</span></a> The positive control strain was an IMP-1-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span> &#40;PSA 319&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib14"><span class="elsevierStyleSup">14</span></a></p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Detection of the bla gene</span><p class="elsevierStylePara elsevierViewall">Because of cost constraints&#44; 15 MBL-positive isolates were selected as representative strains for the detection of genes encoding Ambler class B &#946;-lactamase of the VIM&#44; IMP&#44; or SPM type by PCR using the following specific primers &#40;reading 5&#8242;-3&#8242;&#41;&#58; <span class="elsevierStyleItalic">vim</span> forward&#44; GTCTATTTGACCGCGTC&#44; <span class="elsevierStyleItalic">vim</span> reverse&#59; CTACTCAACGACTGAGCG&#59; <span class="elsevierStyleItalic">imp</span> forward&#44; ATGAGCAAGTTATCTGTATTC&#44; <span class="elsevierStyleItalic">imp</span> reverse&#58; GTCGCAACGACTGTGTAG and <span class="elsevierStyleItalic">spm</span> reverse&#58; TCGCCGTGTCCAGGTATAAC&#44; <span class="elsevierStyleItalic">spm</span> forward&#58; CCTACAATCTAACGGCGACC&#46; The cycling parameters were 95<span class="elsevierStyleHsp" style=""></span>&#176;C for 5<span class="elsevierStyleHsp" style=""></span>min&#44; followed by 30 denaturation cycles at 95<span class="elsevierStyleHsp" style=""></span>&#176;C for 1<span class="elsevierStyleHsp" style=""></span>min&#44; annealing at 40<span class="elsevierStyleHsp" style=""></span>&#176;C for 1<span class="elsevierStyleHsp" style=""></span>min&#44; and extension at 68<span class="elsevierStyleHsp" style=""></span>&#176;C for 1<span class="elsevierStyleHsp" style=""></span>min&#46; PCR products were visualized by electrophoresis on 0&#46;8&#37; agarose gels stained with 1&#37; ethidium bromide&#46;<a class="elsevierStyleCrossRefs" href="#bib14"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Genotyping by pulsed-field gel electrophoresis</span><p class="elsevierStylePara elsevierViewall">Among 47 IRPa isolates&#44; 15 randomly selected isolates with a positive MBL-producing phenotype were typed using pulsed-field gel electrophoresis &#40;PFGE&#41;&#44; as described by Denton et al&#44;<a class="elsevierStyleCrossRef" href="#bib16"><span class="elsevierStyleSup">16</span></a> with modifications&#46; Each plug was digested with 30<span class="elsevierStyleHsp" style=""></span>U of <span class="elsevierStyleItalic">SpeI</span> restriction endonuclease &#40;Invitrogen&#44; Carlsbad&#44; CA&#41; at 37<span class="elsevierStyleHsp" style=""></span>&#176;C for 12<span class="elsevierStyleHsp" style=""></span>h&#46; Briefly&#44; electrophoresis was performed by a 1&#37; PFGE agarose gel run on the Gene Navigator &#40;Pharmacia&#44; Amersham Biociences&#41; instrument at 164<span class="elsevierStyleHsp" style=""></span>V for 20&#46;1<span class="elsevierStyleHsp" style=""></span>h&#44; at 14<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; The equipment was adjusted for a pulse of 5<span class="elsevierStyleHsp" style=""></span>s for 20<span class="elsevierStyleHsp" style=""></span>h and 15<span class="elsevierStyleHsp" style=""></span>s for 0&#46;1<span class="elsevierStyleHsp" style=""></span>h&#46; Band patterns were visualized by ethidium bromide staining and ultraviolet transillumination&#46; Cloning was evaluated according to the Tenover criteria&#44;<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a> based on visual comparisons of the band patterns of samples run together in the same gel&#46; Genetic similarities in samples were analyzed with a multivariate statistical package &#40;MVSP 3&#46;0&#41;&#46;</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p class="elsevierStylePara elsevierViewall">Categorical variables were assessed with the chi-square test and Fisher&#39;s exact test&#59; significance was set at a <span class="elsevierStyleItalic">P</span> value of &#10877;0&#46;05&#46; Odds ratios and 95&#37; confidence intervals were calculated with Epi-Info software&#44; version 5&#46;0&#46; Variables were selected by forward logistic regression for the multivariate analysis&#46;</p></span></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStylePara elsevierViewall">Following the index case&#44; 46 additional cases of hospital-acquired infection were documented&#44; including mechanical ventilation-associated pneumonia &#40;41&#41;&#44; bloodstream infection &#40;3&#41;&#44; surgical wound infection &#40;1&#41; and urinary tract infection &#40;1&#41; caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> resistant to imipenem and other antimicrobial agents&#44; including cephalosporins&#44; aminoglycosides&#44; and fluoroquinolones &#40;data not shown&#41;&#46;</p><p class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig1">Fig&#46; 1</a> shows the mortality data and the temporal&#47;spatial relationships &#40;ICU stay&#41; among the 47 patients&#44; which provides evidence of cross-transmission of IRPa&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall">During the scrutiny for contamination&#44; <span class="elsevierStyleItalic">P&#46; aeruginosa</span> was not detected on culture of samples from the hands of 23 professionals&#44; although initially this was suspected as the route by which the microorganism had been disseminated&#46; However&#44; <span class="elsevierStyleItalic">P&#46; aeruginosa</span> was found colonizing 15&#47;86 &#40;17&#46;4&#37;&#41; of the patients examined and on surfaces located near the patients&#44; including the mechanical ventilation nebulizer in 10&#47;86 &#40;11&#46;6&#37;&#41; and the headboard of the bed in 3&#47;86 &#40;3&#46;5&#37;&#41;&#44; but not the sinks&#46;</p><p class="elsevierStylePara elsevierViewall">The majority of imipenem&#47;ceftazidime-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> strains in infected patients &#40;33&#47;43&#59; 76&#46;7&#37;&#41; had an MBL-positive phenotype&#44; with no differences in detection between mercaptopropionic acid or EDTA &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; In the contamination scrutiny&#44; 17&#46;8&#37; &#40;5&#47;28&#41; of <span class="elsevierStyleItalic">P&#46; aeruginosa</span> imipenem&#47;ceftazidime-resistant strains had an MBL-positive phenotype&#46; Only 26&#46;7&#37; &#40;4&#47;15&#41; of MBL-producing strains were positive for the <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM&#8722;1</span></span> gene&#46; The <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">VIM&#8722;2&#44;</span> bla <span class="elsevierStyleInf">IMP&#8722;1&#44;</span></span> and <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM</span></span> genes were not found&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Genotyping</span><p class="elsevierStylePara elsevierViewall">Two strains collected from the environment and strains from tracheal secretions were MBL-producers&#46; A total of 15 strains were typed&#59; however&#44; 2 specimens remained undefined&#46; Four clones and their subclones were found on PFGE&#44; with a predominance of clone A&#44; A1&#44; A2 &#40;61&#46;5&#37;&#41;&#44; followed by B&#44; B1 &#40;23&#46;1&#37;&#41;&#44; C and D &#40;1 sample each&#41;&#44; and 2 indeterminate results &#40;<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a> shows the univariate analysis&#46; On multivariate analysis&#44; age &#10878;60 years &#40;<span class="elsevierStyleItalic">P</span>&#10877;0&#46;02&#59; OR 2&#46;4&#59; 95&#37; CI 1&#46;10&#8211;5&#46;49&#41;&#44; use of mechanical ventilation &#40;<span class="elsevierStyleItalic">P</span>&#10877;0&#46;001&#59; OR 7&#46;2&#59; 95&#37; CI 2&#46;74&#8211;19&#46;10&#41;&#44; presence of a tracheotomy &#40;<span class="elsevierStyleItalic">P</span>&#10877;0&#46;02&#59; OR 4&#46;01&#59; CI 1&#46;17&#8211;13&#46;72&#41;&#44; and carbapenem use &#40;<span class="elsevierStyleItalic">P</span>&#60;0&#46;001&#44; OR 5&#46;7&#59; 95&#37; CI 2&#46;31&#8211;10&#46;08&#41; were risk factors for acquiring imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> infection</p><elsevierMultimedia ident="tbl3"></elsevierMultimedia></span></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara elsevierViewall">The presence of MBL-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span> has been described in many hospitals around the world&#46;<a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a> Nonetheless&#44; dissemination of an <span class="elsevierStyleItalic">SPM-1</span> MBL-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span> epidemic has been demonstrated only in hospitals of different Brazilian regions&#46;<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8&#44;14&#44;19</span></a> As compared to other studies carried out in Brazil&#44; the presently reported nosocomial outbreak of imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> infection involved the largest number of cases to date &#40;47 patients&#41; and was associated with 4 clones&#46; This study is the first to include an expressive number &#40;&#8776;60&#37;&#41; of critical IRPa-infected patients who died within 30 days after the infection&#46;</p><p class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> is a leading pathogen in mechanical ventilation-associated nosocomial pneumonia&#44; with an associated mortality rate of 20&#37; to 80&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8&#44;9&#44;20</span></a> During the outbreak in our hospital&#44; pneumonia was the predominant infection&#44; accounting for more than two-thirds &#40;85&#37;&#41; of the cases&#44; followed by bloodstream infection and surgical wounds&#46;</p><p class="elsevierStylePara elsevierViewall">The multivariate logistic regression analysis showed that patients with nosocomial IPRa infection were more likely to have been exposed to mechanical ventilation&#44; and that tracheotomy and use of carbapenems were predisposing factors for the infection&#46; These findings are consistent with those of other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib4"><span class="elsevierStyleSup">4&#44;20&#8211;22</span></a></p><p class="elsevierStylePara elsevierViewall">Although the advent of carbapenems in the 1980s heralded a new treatment option for serious bacterial infections&#44; carbapenem resistance is now observed in Enterobacteriaceae and <span class="elsevierStyleItalic">Acinetobacter</span> spp&#46;&#44; and is becoming commonplace in <span class="elsevierStyleItalic">P&#46; aeruginosa&#46;</span><a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleItalic">P&#46; aeruginosa</span> possessing MBLs has been increasingly reported worldwide&#44; mainly in ICUs and including Brazil&#44;<a class="elsevierStyleCrossRefs" href="#bib14"><span class="elsevierStyleSup">14&#44;18&#44;19</span></a> but at rates comparatively lower than those found in our study &#40;&#8776;90&#37;&#41;&#46;</p><p class="elsevierStylePara elsevierViewall">These enzymes are clinically relevant because of their ability to hydrolyze most &#946;-lactams&#44; including carbapenems &#40;but excluding aztreonam&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a> and their association with mobile genetic elements&#44; increasing the possibility of rapid spread&#46;<a class="elsevierStyleCrossRefs" href="#bib19"><span class="elsevierStyleSup">19&#44;23&#8211;25</span></a> In the Americas&#44; 6 different MBLs have been described in <span class="elsevierStyleItalic">P aeruginosa</span>&#44; including SPM-1&#44; IMP-1&#44; IMP-16&#44; VIM-2&#44; VIM-8 and VIM-11<a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a> and three MBL types &#40;SPM-1&#44; VIM-2 and IMP-1&#41; have been detected in Brazilian hospitals&#44; with most strains expressing <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM&#8722;1</span></span>&#44; which is disseminated among our hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8&#44;14&#44;19&#44;22</span></a> We found that MBL-producing strains accounted for a substantial number of cases &#40;76&#46;7&#37;&#41;&#44; and that the strains were clinically relevant&#44; because 70&#46;0&#37; of the patients died&#46; In contrast to the reported results of Sader et al&#44;<a class="elsevierStyleCrossRef" href="#bib26"><span class="elsevierStyleSup">26</span></a> neither <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">IMP&#8722;1</span></span> or <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">VIM&#8722;1</span></span> genes were found in this study&#46;</p><p class="elsevierStylePara elsevierViewall">The acquisition of resistant bacteria in hospitals may be a consequence of selective pressure exerted by the use of antibiotics and&#47;or horizontal dissemination&#46;<a class="elsevierStyleCrossRef" href="#bib27"><span class="elsevierStyleSup">27</span></a> Molecular typing of strains presenting the <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM&#8722;1</span></span> gene showed the presence of a single clone &#40;A&#41;&#46; In the present study&#44; multidrug-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> strains were clustered in two major genotypes&#59; these showed coresistance to most of the antimicrobial agents tested&#46; Multidrug resistance can be explained by the accumulation of several resistance mechanisms&#44; including gene mutation&#44; over-expression of efflux pumps&#44; loss or modification of porins&#44; and acquired extended-spectrum &#946;-lactamases&#46;<a class="elsevierStyleCrossRef" href="#bib28"><span class="elsevierStyleSup">28</span></a> This suggests that the selective pressure of previous antimicrobial use in the unit contributed to the emergence of resistant clones&#46;</p><p class="elsevierStylePara elsevierViewall">Both the SPM and non-SPM-infected patients were clustered for 18 months in a single unit&#44; with overlapping during their hospitalization&#46; These data suggest that horizontal transmission between these patients may have played a role in the dissemination of the infection&#46; Clonal dissemination was detected within and between intensive care units in S&#227;o Paulo &#40;4&#41; and Brasilia&#44;<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a> but with unrelated strains recovered from one of them&#46; These data differ from those of Pellegrino et al<a class="elsevierStyleCrossRef" href="#bib29"><span class="elsevierStyleSup">29</span></a> who reported clonal dissemination between private and public institutions in Rio de Janeiro&#44; in which both presented an apparently endemic background&#46;</p><p class="elsevierStylePara elsevierViewall">Detection of clonal dissemination usually indicates inadequate nosocomial infection control practice&#46;<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a> This outbreak of <span class="elsevierStyleItalic">P&#46; aeruginosa</span> infection was probably linked to transmission of the microorganism via the hands of healthcare workers&#46; We did not identify hand carriage among the workers examined&#44; but a spatial&#47;temporal relationship was seen among the cases in our unit&#44; and low adherence &#40;23&#37;&#41; to proper hand washing<a class="elsevierStyleCrossRef" href="#bib30"><span class="elsevierStyleSup">30</span></a> practice was detected in a recent study&#46;</p><p class="elsevierStylePara elsevierViewall">In conclusion&#44; to our knowledge&#44; this is the first study to conduct an analysis using both classical and molecular techniques of an outbreak of infection associated with a highly prevalent MBL-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#44; including mainly <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM&#8722;1</span></span> strains clustered in 2 major genotype&#44; resulting in a significant increase in mortality of elderly patients and in previous use of antibiotics&#46; The clonal dissemination among patients in our unit indicates problems in nosocomial infection control practice&#44; likely associated with low adherence to hand hygiene&#44; and selective pressure that provides resistant strains with an advantage over their susceptible ancestors&#46;</p></span></span>"
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          "titulo" => array:5 [
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivo"
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          "titulo" => "Palabras clave"
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        4 => array:1 [
          "titulo" => "Introduction"
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        5 => array:2 [
          "titulo" => "Methods"
          "secciones" => array:8 [
            0 => array:1 [
              "titulo" => "Hospital"
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            1 => array:1 [
              "titulo" => "Study design"
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            2 => array:1 [
              "titulo" => "Data collection"
            ]
            3 => array:1 [
              "titulo" => "Identification and susceptibility testing procedures"
            ]
            4 => array:1 [
              "titulo" => "Phenotypic metallo-&#946;-lactamase production"
            ]
            5 => array:1 [
              "titulo" => "Detection of the bla gene"
            ]
            6 => array:1 [
              "titulo" => "Genotyping by pulsed-field gel electrophoresis"
            ]
            7 => array:1 [
              "titulo" => "Statistical analysis"
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          ]
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        6 => array:2 [
          "titulo" => "Results"
          "secciones" => array:1 [
            0 => array:1 [
              "titulo" => "Genotyping"
            ]
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        7 => array:1 [
          "titulo" => "Discussion"
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        8 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2008-01-25"
    "fechaAceptado" => "2008-09-01"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec137868"
          "palabras" => array:4 [
            0 => "Nosocomial outbreak"
            1 => "Imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span>"
            2 => "Metallo-&#946;-lactamase"
            3 => "Intensive care unit"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec137867"
          "palabras" => array:4 [
            0 => "Brote nosocomiales"
            1 => "<span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> resistente la imipenem"
            2 => "Metallo-&#946;-lactamase"
            3 => "Unidad de cuidados intensivos"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p class="elsevierStyleSimplePara elsevierViewall">To describe an outbreak of imipenem-resistant metallo-&#946;-lactamase-producing <span class="elsevierStyleItalic">Pseudomonas aeruginosa&#44;</span> enzyme type <span class="elsevierStyleItalic">bla</span>&#44; by horizontal transmission in patients admitted to a mixed adult ICU&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p class="elsevierStyleSimplePara elsevierViewall">A case-control study was carried out&#44; including 47 patients &#40;cases&#41; and 122 patients &#40;control&#41; admitted to the mixed ICU of a university hospital in Minas Gerais&#44; Brazil from November 2003 to July 2005&#46; The infection site&#44; risk factors&#44; mortality&#44; antibiotic susceptibility&#44; metallo-&#946;-lactamase &#40;MBL&#41; production&#44; enzyme type&#44; and clonal diversity were analyzed&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">A temporal&#47;spatial relationship was detected in most patients &#40;94&#37;&#41;&#44; overall mortality was 55&#46;3&#37;&#44; and pneumonia was the predominant infection &#40;85&#37;&#41;&#46; The majority of isolates &#40;95&#37;&#41; were resistant to imipenem and other antibiotics&#44; except for polymyxin&#44; and showed MBL production &#40;76&#46;7&#37;&#41;&#46; Only <span class="elsevierStyleItalic">bla SPM-1</span> &#40;33&#37;&#41; was identified in the 15 specimens analyzed&#46; In addition&#44; 4 clones were identified&#44; with a predominance of clone A &#40;61&#46;5&#37;&#41; and B &#40;23&#46;1&#37;&#41;&#46; On multivariate analysis&#44; advanced age&#44; mechanical ventilation&#44; tracheostomy&#44; and previous imipenem use were significant risk factors for imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span> infection&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">Clonal dissemination of MBL-producing <span class="elsevierStyleItalic">P&#46; aeruginosa</span> strains with a spatial&#47;temporal relationship disclosed problems in the practice of hospital infection control&#44; low adherence to hand hygiene&#44; and empirical antibiotic use&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p class="elsevierStyleSimplePara elsevierViewall">Describir un brote causado por <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> resistente a imipenem productora de metallo-&#946;-lactamasa &#40;MBL&#41;&#44; tipo de bla de la enzima&#44; con transmisi&#243;n horizontal de la muestra epid&#233;mica en pacientes ingresados en una unidad de cuidados intensivos para adultos mixta&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p class="elsevierStyleSimplePara elsevierViewall">Durante el per&#237;odo comprendido entre noviembre de 2003 y julio de 2005&#44; se realiz&#243; un estudio de casos y controles en el que se incluy&#243; a 47 &#40;casos&#41; y 122 &#40;control&#41; pacientes en una unidad de cuidados intensivos para adultos mixta&#44; de un hospital universitario de Uberl&#226;ndia &#40;Minas Gerais &#91;Brasil&#93;&#41;&#46; Se analizaron los sitios de la infecci&#243;n&#44; los factores de riesgo&#44; la mortalidad total&#44; la susceptibilidad a los antibi&#243;ticos&#44; la producci&#243;n del tipo MBL&#44; de la enzima y de la diversidad clonal&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">En la mayor&#237;a de los pacientes &#40;94&#37;&#41; se detect&#243; una relaci&#243;n temporal&#47;espacial&#46; El &#237;ndice de mortalidad total fue del 55&#44;3&#37; y la neumon&#237;a era la infecci&#243;n predominante &#40;85&#37;&#41;&#46; La mayor&#237;a de las cepas &#40;95&#37;&#41; era resistente a imipenem y a otros antibi&#243;ticos&#44; excepto al polimixin y la producci&#243;n de MBL &#40;76&#44;7&#37;&#41;&#46; &#218;nicamente se identific&#243; bla<span class="elsevierStyleItalic"><span class="elsevierStyleInf">SPM&#8722;1</span></span> en los 15 espec&#237;menes analizados&#46; Adem&#225;s&#44; se detectaron 4 clones&#44; con predominio del clon A &#40;61&#44;5&#37;&#41; y B &#40;23&#44;1&#37;&#41;&#46; En an&#225;lisis multivariados&#44; la vejez&#44; la ventilaci&#243;n mec&#225;nica&#44; la traqueotom&#237;a y el uso previo del carbapenem son factores de riesgo significativos para el desarrollo de la infecci&#243;n de <span class="elsevierStyleItalic">P&#46; aeruginosa</span> resistente a imipenem&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">La diseminaci&#243;n clonal de cepas de <span class="elsevierStyleItalic">P&#46; aeruginosa</span> productora de MBL entre los pacientes con una relaci&#243;n temporal&#47;espacial mostr&#243; problemas en el control de la infecci&#243;n del hospital&#44; probablemente relacionado con una adherencia baja a la higiene de las manos y el uso emp&#237;rico de los antibi&#243;ticos&#46;</p>"
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          "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Schematic representation of temporal and spatial relationships among patients infected with imipenem-resistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> during the study period&#46; The arrows represent referral of patients from other hospitals to the ICU in Uberlandia Federal University Hospital&#44; black sections indicate the time the patient was another ward&#44; sections with hatched lines indicate time the patient was in the ICU and infected by imipenem-resistant <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#44; and crosses indicate death of the patient&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&#47;n IRPa &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn1ast"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ventilation-associated pneumonia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urinary tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;1 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#47;43 &#40;94&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab243797.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn1ast"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara"><span class="elsevierStyleItalic">Pseudomonas aeruginosa-</span>infected patients&#47;number of infections by IRPa&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Infections by imipenem-resistant metallo-&#946;-lactamase-producing <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> in ICU patients at Uberlandia Federal University Hospital</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl2"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Isolation period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Source &#40;n isolates&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">IRPa positive for <span class="elsevierStyleItalic">bla<span class="elsevierStyleInf">SPM&#8722;1</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">PGFE profile&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">December 2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">March&#44; April 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Breath &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">January&#44; February 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestine &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">March 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headboard &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND<a class="elsevierStyleCrossRef" href="#tblfn2ast"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">February 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">January 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestine &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">October 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">February 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestine &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">January&#44; November 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tracheal secretion &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab243798.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn2ast"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara">Not determined&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Data on 15 metallo-&#946;-lactamase-producing <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> isolates at the Uberlandia Federal University Hospital ICU</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl3"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p class="elsevierStyleSimplePara elsevierViewall">OR&#58; odds ratio&#59; 95&#37; CI&#58; 95&#37; confidence interval&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Patients</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Infected n&#61;47 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Noninfected n&#61;122 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn3ast"><span class="elsevierStyleSup"><span class="elsevierStyleItalic">&#42;</span></span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&#47;Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#47;30 &#40;36&#46;2&#47;63&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#47;60 &#40;50&#46;8&#47;49&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;55 &#40;0&#46;56&#8211;1&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#44; y</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#10878;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;41&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;44 &#40;0&#46;19&#8211;1&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Length of stay&#44; days</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#10878;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;93&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;16&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;14 &#40;10&#46;59&#8211;83&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comorbid conditions</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">03 &#40;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">07 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;08 &#40;0&#46;41&#8211;2&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">03 &#40;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;22&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;32 &#40;0&#46;11&#8211;0&#46;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AIDS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">02 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">00 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;71 &#40;2&#46;89&#8211;4&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">03 &#40;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">03 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;85 &#40;0&#46;80&#8211;4&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive Devices</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Central venous catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;63&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;90&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;37 &#40;0&#46;24&#8211;0&#46;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mechanical ventilation&#59; MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;95&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;65&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;92 &#40;2&#46;00&#8211;31&#46;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of MV&#44; days</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#10878;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;85&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;10 &#40;0&#46;04&#8211;0&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trauma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;25&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;18&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;381&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;36 &#40;0&#46;80&#8211;2&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;59&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;24&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;82 &#40;1&#46;73&#8211;4&#46;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotic use</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#10878;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;59&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;39&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;27 &#40;1&#46;08&#8211;4&#46;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cephalosporin &#40;3rd&#47;4th generation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2008.09.009

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2021 May	21	10	31
2021 April	21	15	36
2021 March	20	9	29
2021 February	28	9	37
2021 January	20	15	35
2020 December	12	11	23
2020 November	17	8	25
2020 October	18	7	25
2020 September	28	13	41
2020 August	24	14	38
2020 July	14	12	26
2020 June	17	9	26
2020 May	23	7	30
2020 April	14	5	19
2020 March	15	8	23
2020 February	18	6	24
2020 January	18	4	22
2019 December	20	11	31
2019 November	13	8	21
2019 October	12	7	19
2019 September	17	6	23
2019 August	23	4	27
2019 July	13	4	17
2019 June	22	11	33
2019 May	72	28	100
2019 April	24	19	43
2019 March	4	7	11
2019 February	5	6	11
2019 January	7	9	16
2018 December	6	15	21
2018 November	6	3	9
2018 October	14	14	28
2018 September	17	5	22
2018 August	2	2	4
2018 July	9	9	18
2018 June	4	1	5
2018 May	9	10	19
2018 April	5	0	5
2018 March	2	3	5
2018 February	5	1	6
2018 January	4	0	4
2017 December	5	4	9
2017 November	10	3	13
2017 October	4	2	6
2017 September	9	10	19
2017 August	14	1	15
2017 July	10	3	13
2017 June	15	8	23
2017 May	29	3	32
2017 April	20	3	23
2017 March	18	14	32
2017 February	9	3	12
2017 January	13	2	15
2016 December	18	4	22
2016 November	15	4	19
2016 October	46	3	49
2016 September	25	6	31
2016 August	25	6	31
2016 July	11	2	13
2016 June	27	9	36
2016 May	18	12	30
2016 April	9	25	34
2016 March	14	15	29
2016 February	20	12	32
2016 January	18	15	33
2015 December	18	15	33
2015 November	23	17	40
2015 October	11	10	21
2015 September	18	12	30
2015 August	7	3	10
2015 July	12	1	13
2015 June	6	2	8
2015 May	11	4	15
2015 April	8	3	11
2015 March	6	14	20
2015 February	18	9	27
2015 January	22	2	24
2014 December	42	3	45
2014 November	29	3	32
2014 October	38	1	39
2014 September	30	1	31
2014 August	24	2	26
2014 July	49	1	50
2014 June	28	0	28
2014 May	33	2	35
2014 April	26	2	28
2014 March	19	0	19
2014 February	21	2	23
2014 January	20	2	22
2013 December	32	1	33
2013 November	27	8	35
2013 October	43	25	68
2013 September	28	11	39
2013 August	33	5	38
2013 July	19	3	22
2009 April	1086	0	1086

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