New procedure for rapid identification of microorganisms causing urinary tract infection from urine samples by mass spectrometry (MALDI-TOF) | Enfermedades Infecciosas y Microbiología Clínica

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Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Infecc Microbiol Clin. 2015;33:84-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4164 "formatos" => array:3 [ "EPUB" => 10 "HTML" => 2507 "PDF" => 1647 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Serotipos y patrones de resistencia antibiótica en aislados betahemolíticos de Streptococcus agalactiae de madres colonizadas y recién nacidos con enfermedad invasiva" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "84" "paginaFinal" => "88" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Serotypes and antibiotic resistance patterns in beta-hemolytic Streptococcus agalactiae isolates in 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"Rosa-Fraile" ] 7 => array:2 [ "nombre" => "José María" "apellidos" => "Navarro-Marí" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X14001281?idApp=UINPBA00004N" "url" => "/0213005X/0000003300000002/v3_201706020006/S0213005X14001281/v3_201706020006/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "New procedure for rapid identification of microorganisms causing urinary tract infection from urine samples by mass spectrometry (MALDI-TOF)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "89" "paginaFinal" => "94" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gabriel Alberto March Rosselló, María Purificación Gutiérrez Rodríguez, Raúl Ortiz de Lejarazu Leonardo, Antonio Orduña Domingo, Miguel Ángel Bratos Pérez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Gabriel Alberto" "apellidos" => "March Rosselló" "email" => array:1 [ 0 => "gmr810@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María Purificación" "apellidos" => "Gutiérrez Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Raúl" "apellidos" => "Ortiz de Lejarazu Leonardo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "Orduña Domingo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Miguel Ángel" "apellidos" => "Bratos Pérez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departmento de Microbiología, Facultad de Medicina, Universidad de Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevo procedimiento para la identificación rápida en muestras de orina de organismos causantes de infecciones del tracto urinario por espectometría de masas (MALDI-TOF)" ] ] "textoCompleto" => "IntroductionUrinary tract infections (UTIs) can manifest in a wide clinical range from bacteriuria with limited clinical symptoms to sepsis, severe sepsis or septic shock<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. In 20–30% of all septic patients the infection focus is localized in the urogenital tract<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and an adequate initial antibiotic therapy is essential since it ensures improved outcome<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. Moreover, inappropriate antimicrobial therapy in severe UTI is linked to a higher mortality rate<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. For election of the empiric treatment in these cases, identification directly from urine samples of bacteria causing infection can be useful.Matrix assisted laser desorption/ionization-time of flight (MALDI-TOF) technology is a technique which allows microbial identification in clinical microbiology laboratories based on microbial protein profiles<a class="elsevierStyleCrossRef" href="#bib0025">5</a>. A promising application of the MALDI-TOF technique consists of carrying out identification from direct urine samples, without the need to cultivate them. In this way, a result at microbiological species level can be obtained in less than one hour.Validation criteria of the results indicated by the manufacturers are restrictive, such that only high scoring identification is accepted. On the other hand, when microbial identification is carried out by MALDI-TOF from direct samples, the identification scores obtained are lower than scores obtained from culture, as a result of possible analytical interferences, which were not eliminated. So, in order to accept a higher rate of identification, the required level of validation criterion from the manufacturer should be lowered. In fact, various criteria have been published for validation of results that provided different rates of acceptable direct identifications<a class="elsevierStyleCrossRefs" href="#bib0030">6–9</a>.The objectives of this study were (i) to develop a differential centrifugation protocol which allows the identification of microorganisms by MALDI-TOF from direct urine samples, (ii) to propose a new validating criterion for the results that allows to increase the number of acceptable direct identifications, and (iii) to examine the influence of bacterial concentration in urine on the accuracy of direct identification by MALDI-TOF.Material and methodsDetermination of sample sizeAssuming that the population was made up of positive urine samples in the period of one year (3272 in 2010 at Microbiology Service at the University Clinic Hospital of Valladolid, Spain) and accepting an alpha risk of 0.95 giving a precision of ±0.1 units in bilateral contrast to a proportion estimated at 0.5, for the validation of the differential centrifugation protocol, the study group would need to be made up of 95 monobacterial positive urine samples with counts of ≥1×105CFU/ml. A hundred samples were randomly processed to facilitate calculation. The samples were obtained through midstream clean catch and only monobacterial samples were selected because more than 95% UTIs are caused by single bacterial species<a class="elsevierStyleCrossRef" href="#bib0050">10</a>.In order to study the relationship between bacterial concentration in urine samples and the accuracy of identification by MALDI-TOF from direct samples, 37 urines with counts of <1×105CFU/ml were processed (14 samples with counts between 5×104and 1×105CFU/ml, 17 samples with counts between 1×104 and 5×104CFU/ml, and six samples with counts <1×104CFU/ml). Additionally, four samples with yeast were processed. Briefly, a total of 141 monomicrobial positive urine samples were processed.Working procedureIn order to obtain direct identification, the urine samples were processed as follows: samples were homogenized by agitation, and 5ml was centrifuged for 5min at 700rpm. The supernatant obtained was centrifuged for 15min at 6000rpm. The sediment was resuspended in 1ml of HPLC quality distilled water and was centrifuged again for 15min at 6000rpm. The proteins of the sediment were extracted using the ethanol/formic acid technique. In order to carry out this extraction the sample was mixed with 300μl of HPLC quality distilled water and 900μl of absolute ethanol, and vortexed until a homogeneous suspension was achieved. The mixture was centrifuged for 2min at 13,000rpm and the supernatant was eliminated. Finally, 25μl of 70% formic acid and 25μl of acetonitrile were added, vortexed and centrifuged for 1min at 13,000rpm. Using the supernatant obtained, four 1μl spots were dropped on four different areas of the metal sample plate (MSP 96 target polished steel; Bruker, Bremen, Germany). They were allowed to dry and 1μl of the matrix solution (saturated solution of cyano-4-hydroxy cinnamic acid in 50% acetonitrile with 2.5% trifluoroacetic acid) was added to each spot to be analyzed. They were allowed to dry again and then, a reading of the four spots from each sample was taken. All chemicals were supplied by Sigma–Aldrich (St Louis, MO, USA).Furthermore, at the same time, urine samples were plated, using a calibrated loop so as to determine the number or CFU/ml present in the urine, on Columbia agar plates supplemented with 5% sheep's blood (bioMérieux, Marcy l’Etoile, France) and MacConkey medium (bioMérieux, Marcy l’Etoile, France); in addition a Sabouraud+Chloramphenicol agar plate (Difco, Maryland, USA) was added in those cases where fungal analysis was requested. The plates were incubated at 37°C/24h in aerobic atmosphere and identification was done by MALDI technique. Samples showing growth of two or more microorganisms were not included in the study.Protein analysis was carried out using a mass spectrometer MALDI Microflex LT (BrukerDaltoniK GmbH, Bremen, Germany) with FLexControl v. 3.0 software (Bruker DaltoniK GmbH, Bremen, Germany). The spectrum was obtained in linear mode (N2 laser frequency and wavelength: 60Hz and 337nm, voltage of the ion source I: 20kV, voltage of the ion source II: 16.7kV; detector mass range: 2000–20,137Da) and 240 shots from different positions of the metal sample plate were recorded. Once the association is completed, the Biotyper v.3.0 software (Bruker DaltoniK GmbH, Bremen, Germany) suggests a list of ten most likely microorganism identifications, each with a score that indicates its accuracy<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>. Adopting the manufacturer's criteria, valid identifications may be deemed as those in which a score of ≥2.000 is obtained for the first microorganism on the list. The software also offered a consistency index, which provides information concerning the quality of the identification that does not affect the validity of the results. This consistency index depends on the concordance of the microbial identification obtained on the ten microorganisms on the list.Results of the identification were interpreted in accordance with previously published criteria<a class="elsevierStyleCrossRefs" href="#bib0030">6–9</a>; in those cases in which the criteria of the different authors were based on a single reading, the first of the four replicates carried out was chosen and the remaining three replicates were rejected. For this, urine samples were divided into two subgroups, one including the study group of 100 monobacterial samples with counts of ≥1×105CFU/ml, and another including the 37 urine samples with counts of <1×105CFU/ml. Moreover, for each urine sample, MALDI-TOF scores from direct sample and from colonies grown on plates were compared and, taking the identification obtained by MALDI-TOF from culture using the criteria of the manufacturer as the gold standard, a validation criterion for direct identification was defined.In order to compare the identification results obtained using the different validation criteria, the McNemar test was used. In order to compare the frequency distribution in the population of the study group, the Chi-squared test was used. All these calculations were carried out using the SPSS software v. 15.0.ResultsNo statistically significant difference was observed (p>0.05) when comparing isolates obtained from the study group with those from the University Clinic Hospital of Valladolid (Spain) during 2010 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Moreover, the four species most frequently isolated in the urine samples from the Hospital were the same as those in the study group; these were, in order of greater to lesser prevalence, Escherichia coli with isolate percentages of 56% in the Hospital and 51% in the study group, Enterococcus faecalis with percentages of 18% and 11% respectively, Klebsiella pneumoniae with percentages of 7.9% and 11% respectively and Proteus mirabilis with percentages of 4.5% and 4% respectively. Of the 100 urine samples that comprised the study group, 63 were from women and 37 from men. The age of the patients was between 4 and 94 years, with an average age of 69 years; and 23 of them were hospitalized.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Urine samples with counts of ≥1×105CFU/ml produced higher identification scores (close to or above 2.000) in the majority of cases. On the other hand, the identification scores from urine with counts of <1×105CFU/ml were lower, such that identifications with scores <1.400 corresponded with microorganisms which are rarely etiological agents of urinary infection and, in numerous occasions, in one or more determinations of the four microorganisms carried out from the samples no peaks were obtained. Moreover, when scores were ≥1.400, despite the fact that the proposed microorganisms were included among the frequent UTIs source, and the identification proposed for each spot was different, the score was not a sufficient criterion for determining the identification of the bacteria, given that, in many cases, the suggestion with a higher score did not coincide with the identification obtained from culture. In this way, we observed that taking as valid the identification that was repeated at least in two of the four spots with counts of ≥1.400, we obtained 100% concordance in respect of the identifications carried out from culture.Based on these data, we proposed the following validation criterion: a microorganism was correctly identified using MALDI-TOF when, after having taken four readings of the same sample, at least two readings offer the same identification proposal at species level for the first microorganism in the list, both with a score of ≥1.400.Identification results obtained from all urine samples processed in accordance with the validation criteria adopted are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. When the identification results obtained from the study group by applying the criterion proposed in this study were compared with those obtained by applying the validation criteria of different authors<a class="elsevierStyleCrossRefs" href="#bib0030">6–9</a>, no statistically significant differences were observed (p>0.05). On the other hand, when the identification results from the 37 urine samples with counts of <1×105CFU/ml by applying the criterion proposed in this study were compared, we obtained statistically significant differences with respect to those obtained using the criteria of Moussaoui et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> (p<0.05), Schubert et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> (p<0.05) and Stevenson et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> (p<0.05); however, no statistically significant differences were observed (p>0.05) with respect to the criterion of La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045">9</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Bacterial identification results obtained by MALDI-TOF from 137 urine samples by applying the validation criterion proposed in this study are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Of the 51 samples with counts of ≥1×105CFU/ml in which E. coli was identified from culture, there was only one failed identification from direct urine. The eleven isolates of K. pneumoniae, the four of P. mirabilis and Klebsiella oxytoca, the three of Citrobacter freundii, and the one of Enterobacter aerogenes and Serratia marcescens identified from culture were correctly identified from urine. Finally, of the two samples in which Enterobacter cloacae was isolated, correct identification was obtained in one of them. Of the four samples in which non-fermenting Gram-negative rods (NFGNR) were identified (two urine samples with Pseudomonas aeruginosa, one with Acinetobacter baumannii and one with Acinetobacter genomospecies 3), there was only one failed identification, which corresponded to a urine with P. aeruginosa. Staphylococci were isolated in four samples (two urine samples with Staphylococcus aureus, one with Staphylococcus epidermidis and one with Staphylococcus saprophyticus); in this set of four samples, only one correct direct identification was obtained, which corresponded to one isolate of S. aureus. E. faecalis was isolated from eleven samples, and from ten of them correct identification was obtained from urine directly. In the same way, two correct identifications were obtained from a set of five samples with Streptococcus agalactiae. In this way, a 90% sensitivity was obtained (confidence interval of 95%: 81.96–94.84).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Of the 37 urine samples with counts of <1×105CFU/ml direct identification was achieved in seven of them. Of the 14 urine samples with counts between 5×104 and 1×105CFU/ml there were ten with Gram-negative bacterial isolates, and from these three correct identifications were obtained, which were two isolates of E. coli and one of K. pneumoniae. Three isolates of E. coli, one of P. mirabilis and one of Morganella morganii were not identified from the sample directly. On the other hand, of the four samples with Gram-positive bacterial isolates (two urines with an isolate of E. faecalis, one with Enterococcus faecium and one with S. agalactiae) only one identification of E. faecalis was obtained.Of the 17 urine samples with counts between 1×104 and 5×104CFU/ml there were 11 with Gram-negative bacterial isolates which provided three acceptable identifications of E. coli from a direct sample; three isolates of E. coli, two of P. mirabilis and three of P. aeruginosa were not identified. In the six samples with Gram-positive bacterial isolates no correct identification was obtained. In this case, the strains identified from culture were one of S. aureus, four of E. faecalis and one of S. agalactiae.Of the six urine samples processed with counts of <1×104CFU/ml, no valid identification was obtained. Five strains of E. coli and one of P. mirabilis were identified from culture.As can be seen in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, as the bacterial concentration was reduced in the samples, the percentages of identification and average scores obtained were also reduced. For each urinary bacterial concentration, the bacteria belonging to the family Enterobacteriaceae showed the greater percentage of correct identifications and higher average score, and in the same way, the percentage of correct identifications and the average score in Gram-negative bacteria were greater than that of Gram-positive bacteria.In the identification of yeasts by MALDI-TOF from four urine samples, the species identified from culture was Candida albicans. In the two urine samples with counts of ≥1×105CFU/ml identification was obtained with an average score of 1.989, and in the two with counts between 1×104 and 5×104CFU/ml no valid identification was obtained.DiscussionThis paper was focused on the direct microbial identification in urine samples regardless of their concentration because, apart from the classic criterion described by Kass<a class="elsevierStyleCrossRef" href="#bib0065">13</a>, it had demonstrated that counts of <1×105CFU/ml of bacteria and yeasts might be indicative of UTI in samples obtained through midstream clean catch<a class="elsevierStyleCrossRefs" href="#bib0070">14–18</a>.The criteria for validation of results obtained using MALDI-TOF can be classified into two groups: one takes into account the score and consistency index obtained in each reading and the other is based only on the score of the first microorganism in the list. Belonging to the first group two proposals have been reported. So, Moussaoui et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> established that an identification is valid if a score of ≥1.400 is obtained for the first microorganism in the list and the species in the first four identification proposals coincides; similarly, Schubert et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> advocated that an identification is valid if a score of ≥1.500 is obtained for the first microorganism and the species is the same in the first three identification proposals in the list. Based on the score obtained for the first microorganism in the list given by the software, two criteria can be found in the literature, i.e., the one proposed by Stevenson et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>, and subsequently by Prod’hom et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>, Juiz et al.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> and Ferreira et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>, establishing that a score of ≥2.000 in an identification indicates a species level identification, a score between 1.700 and 1.900 indicates a genus level identification, and a score of <1.700 indicates non-identification. Finally, the standard proposed by La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045">9</a> established that a microorganism is identified correctly using MALDI-TOF when, after having performed four identifications of a single sample, the bacterial species with the highest score (the first on the list) coincides in all of them and a score of ≥1.900 is obtained in at least two identifications, or when a score of ≥1.200 is obtained in the four identifications.Urine samples with counts of ≥1×105CFU/ml of Gram-negative bacteria and Enterococcus spp. provided high identification scores (close to 2.000) and therefore high correct identification percentages were obtained, regardless of the validation criteria used. It is worth mentioning that the proposed criterion produced more direct identification percentages in the study group (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). However, for the urine samples with counts of ≥1×105CFU/ml of Staphylococcus spp. or Streptococcus spp. and urine with counts of <1×105CFU/ml, low identification scores (close to 1.400) were obtained, and as a consequence, low identification percentages were obtained. For these urine samples with low scores, the identification percentage obtained depended on the criterion used in validating results and our criterion also produced higher percentages of correct direct identification (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The criteria of Moussaoui et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> and Schubert et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>, which take into account the score and the consistency index, were not suitable for the validation of these urine samples that provided low identification scores. It was due to the lack of concordance at species level on the list of the ten microorganisms proposed by the software, despite the fact that the first option in the list could coincide with the identification obtained from culture. La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045">9</a>, who used lower scores than all those published to date, proposed substituting the consistency index obtained in a reading with the concordance at species level obtained in the first identification of the four readings carried out from the same sample; which is to say, this criterion is based on the score and the reproducibility of the equipment. A limitation of this criterion consists in that proposing valid identification from scores of ≥1.200 is not useful for validating of the results obtained from direct urine samples with low bacterial counts, since we have observed that scores of <1.400 suggested microorganisms which are rarely etiological agents in UTI. Using the criterion proposed in this study, the higher identification score obtained in one of the four readings carried out from one sample was not a determining factor, given that if an identification with a higher score than any other of those repeated was obtained, this should be discarded. So, with the proposed criterion, the weighting of the score was reduced in the validation of results.When 5ml of urine with counts of ≥1×105CFU/ml of Staphylococcus spp. and Streptococcus spp. or with counts of <1×105CFU/ml was processed, the bacterial concentration was insufficient for carrying out direct identification by MALDI-TOF from urine. This suggested that in order to achieve the direct identification successfully it would be better to process greater sample volumes in order to process a greater amount of bacteria.No previous studies on direct identifications of yeasts from urine samples have been found in the literature. Although the number of samples studied in which a yeast was isolated is very low, the results obtained coincided with those from bacteria positive urine with regard to the microbial concentration in the sample; which is to say, the two strains of C. albicans present in two urine samples with counts of ≥1×105CFU/ml were correctly identified by applying our criterion and the two strains isolated in two samples with counts of <1×105CFU/ml were not.Results obtained in this study concur with those of Ferreira et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> and with those of Kohling et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>, which also observed that counts of ≥1×105CFU/ml produced higher percentage of direct identification in urine samples, and that concentrations <1×105CFU/ml produced low percentages of direct identification. Our results also matched with those published by Christner et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>, who pointed out that with greater bacterial concentration in the sample, greater is the quantity of microorganisms deposited on the metal sample plate and consequently a higher score was obtained. In this way, when the bacterial concentration in the urine sample is high (≥1×105CFU/ml) satisfactory identification percentages are obtained, above all in Gram-negative bacteria. In urine with counts between 5×104 and 1×105CFU/ml identification percentages were considerably reduced; in urine with counts between 1×104 and 5×104CFU/ml the percentages were reduced even further; and in urine with counts of <1×104CFU/ml, no direct identification was achieved. Moreover, for each urine bacterial concentration the average score for Gram-negative bacteria obtained is superior to that of Gram-positive bacteria (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>); these data coincides with that published by Schubert et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> who asserted that the MALDI-TOF system offers greater identification capacity for Gram-negative than Gram-positive bacteria.For performing bacterial identification directly from urine samples, the clinician must request it in patients with suspected severe UTI. Direct bacterial identification cannot be applied in all urine samples because they are those most commonly processed in clinical microbiology laboratories<a class="elsevierStyleCrossRef" href="#bib0120">24</a>.Direct identification is reported in less than one hour from the arrival of the urine to the laboratory and only includes the bacterial species present in urine. For confirmation of direct identification and clinical significance, it is necessary to perform bacterial identification and calculate bacterial counts from colonies obtained on isolation plates. Therefore, the clinician must assess clinical significance of direct bacterial identification and adopt appropriate measures regarding antimicrobial therapy.A problem of direct identification by MALDI-TOF is that polymicrobial samples could provide wrong identifications since the spectra obtained include peaks of two or more microorganisms. This problem has been partially solved with the use of software (Bruker DaltoniK GmbH, Bremen, Germany) which, in some cases, is able to report two bacterial identifications if both microorganisms are in correct proportions.To sum up, applying the differential centrifugation protocol together with the validation criterion proposed in this study, it was possible to achieve identification by MALDI-TOF of the microorganisms that most frequently cause UTI from direct monomicrobial urine samples with bacterial counts of ≥1×105CFU/ml; and, it was also possible to improve correct identifications in urine samples with bacterial counts of <1×105CFU/ml.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres847624" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec842576" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres847623" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec842575" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Determination of sample size" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Working procedure" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-12-21" "fechaAceptado" => "2014-02-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec842576" "palabras" => array:3 [ 0 => "MALDI-TOF" 1 => "Direct identification" 2 => "Urine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec842575" "palabras" => array:3 [ 0 => "MALDI-TOF" 1 => "Identificación directa" 2 => "Orina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionMatrix assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry is widely established as a technique in clinical microbiology laboratories for the identification of microorganisms. Using this technique, it is also possible to obtain the identification of microorganisms from untreated urine samples. MethodsIn this study, a differential centrifugation protocol and a criterion for validation of the results in order to achieve microbial identification from untreated urine samples are proposed. Additionally, the sensitivity of the analytical procedure in monobacterial urine samples has been evaluated. ResultsA 90% sensitivity (confidence interval of 81.96%–94.84%) was obtained in urine samples with bacterial counts of ≥1×105CFU/ml, and it was possible to improve the percentages of direct identifications from urine samples with bacterial counts of <1×105CFU/ml. ConclusionIt is concluded that the MALDI-TOF system is both fast and reliable in the identification of individual microorganisms from untreated urine samples with counts of ≥1×105CFU/ml." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl uso de la espectrometría de masas Matrix Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) es una técnica implantada en los laboratorios de Microbiología Clínica que permite llevar a cabo la identificación de microorganismos. Una de las aplicaciones de esta técnica es la identificación a partir de muestra directa de orina. MétodosEn este estudio se propone un protocolo de centrifugación diferencial y un criterio de validación de los resultados para alcanzar la identificación microbiana a partir de muestra directa de orina. Adicionalmente se estudia la sensibilidad del procedimiento analítico en muestras de orina monomicrobianas. ResultadosLas orinas con recuentos ≥1×105UFC/ml mostraron un 90% de sensibilidad (Intervalo de Confianza de 81.96%–94.84%) y se logró mejorar los porcentajes de identificación directa a partir de orinas con recuentas bacterianos <1×105UFC/ml. ConclusionesLa espectrometría de masas MALDI-TOF es un sistema rápido y fiable para la identificación de microorganismos a partir de orinas monomicrobianas con recuentos ≥1×105UFC/ml." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Positive urines year 2010 (N=3272) (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study group (N=100) (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enterobacteriaceae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NFGNR<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Staphylococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Streptococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enterococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other microorganisms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1430824.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "NFGNR: non-fermenting Gram-negative rods." ] ] ] "descripcion" => array:1 [ "en" => "Results of identification obtained by MALDI-TOF from culture of positive urine samples from 2010 and from culture in the study group of 100 urine samples." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author (reference), kind of criterion \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications in 100 urines that form the study group (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications in 37 urines with counts of <1×105CFU/ml n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Moussaoui et al.11, score and consistency index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Schubert et al.12, score and consistency index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stevenson et al.13, score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">La Scola and Raoult14, score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Criterion proposed, score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (18.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1430825.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Frequency of microorganisms identified by MALDI-TOF from 137 monobacterial urine samples related with the validation criterion adopted." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "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"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts of ≥1×105CFU/ml</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts between 5×104 and 1×105CFU/ml</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts between 1×104 and 5×104CFU/ml</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts of <1×104CFU/ml</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications n/N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications n/N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications n/N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications n/N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gram-negative bacteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77/80 (96.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.063 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/10 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.650 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/11 (27.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.456 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/6 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enterobacteriaceae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74/76 (97.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.070 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/8 (37.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.650 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/8 (37.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.456 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NFGNR<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/4 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.809 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/2 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/3 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gram-positive bacteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13/20 (65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.885 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1/4 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.608 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/6 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Staphylococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1/4 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.528 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/1 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S. agalactiae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/5 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.536 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/1 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/4 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enterococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10/11 (90.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.985 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1/3 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.608 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/1 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90/100 (90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.037 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4/14 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.640 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3/17 (17.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.456 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/6 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1430823.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "NFGNR: non-fermenting Gram-negative rods." ] ] ] "descripcion" => array:1 [ "en" => "Frequency of microorganisms identified by MALDI-TOF from direct urine samples related with bacterial concentration applying the criterion proposed in this study." ] ] ] "bibliografia" => 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New procedure for rapid identification of microorganisms causing urinary tract infection from urine samples by mass spectrometry (MALDI-TOF)

Nuevo procedimiento para la identificación rápida en muestras de orina de organismos causantes de infecciones del tracto urinario por espectometría de masas (MALDI-TOF)

Gabriel Alberto March Rossellóa,

Corresponding author

gmr810@hotmail.com

Corresponding author.

, María Purificación Gutiérrez Rodrígueza, Raúl Ortiz de Lejarazu Leonardoa,b, Antonio Orduña Domingoa,b, Miguel Ángel Bratos Péreza,b

a Departmento de Microbiología, Facultad de Medicina, Universidad de Valladolid, Spain

b Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Spain

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            "nombre" => "Miguel &#193;ngel"
            "apellidos" => "Bratos P&#233;rez"
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            "entidad" => "Departmento de Microbiolog&#237;a&#44; Facultad de Medicina&#44; Universidad de Valladolid&#44; Spain"
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      "es" => array:1 [
        "titulo" => "Nuevo procedimiento para la identificaci&#243;n r&#225;pida en muestras de orina de organismos causantes de infecciones del tracto urinario por espectometr&#237;a de masas &#40;MALDI-TOF&#41;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urinary tract infections &#40;UTIs&#41; can manifest in a wide clinical range from bacteriuria with limited clinical symptoms to sepsis&#44; severe sepsis or septic shock<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; In 20&#8211;30&#37; of all septic patients the infection focus is localized in the urogenital tract<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and an adequate initial antibiotic therapy is essential since it ensures improved outcome<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; Moreover&#44; inappropriate antimicrobial therapy in severe UTI is linked to a higher mortality rate<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; For election of the empiric treatment in these cases&#44; identification directly from urine samples of bacteria causing infection can be useful&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Matrix assisted laser desorption&#47;ionization-time of flight &#40;MALDI-TOF&#41; technology is a technique which allows microbial identification in clinical microbiology laboratories based on microbial protein profiles<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; A promising application of the MALDI-TOF technique consists of carrying out identification from direct urine samples&#44; without the need to cultivate them&#46; In this way&#44; a result at microbiological species level can be obtained in less than one hour&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Validation criteria of the results indicated by the manufacturers are restrictive&#44; such that only high scoring identification is accepted&#46; On the other hand&#44; when microbial identification is carried out by MALDI-TOF from direct samples&#44; the identification scores obtained are lower than scores obtained from culture&#44; as a result of possible analytical interferences&#44; which were not eliminated&#46; So&#44; in order to accept a higher rate of identification&#44; the required level of validation criterion from the manufacturer should be lowered&#46; In fact&#44; various criteria have been published for validation of results that provided different rates of acceptable direct identifications<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of this study were &#40;i&#41; to develop a differential centrifugation protocol which allows the identification of microorganisms by MALDI-TOF from direct urine samples&#44; &#40;ii&#41; to propose a new validating criterion for the results that allows to increase the number of acceptable direct identifications&#44; and &#40;iii&#41; to examine the influence of bacterial concentration in urine on the accuracy of direct identification by MALDI-TOF&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Determination of sample size</span><p id="par0025" class="elsevierStylePara elsevierViewall">Assuming that the population was made up of positive urine samples in the period of one year &#40;3272 in 2010 at Microbiology Service at the University Clinic Hospital of Valladolid&#44; Spain&#41; and accepting an alpha risk of 0&#46;95 giving a precision of &#177;0&#46;1 units in bilateral contrast to a proportion estimated at 0&#46;5&#44; for the validation of the differential centrifugation protocol&#44; the study group would need to be made up of 95 monobacterial positive urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#46; A hundred samples were randomly processed to facilitate calculation&#46; The samples were obtained through midstream clean catch and only monobacterial samples were selected because more than 95&#37; UTIs are caused by single bacterial species<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to study the relationship between bacterial concentration in urine samples and the accuracy of identification by MALDI-TOF from direct samples&#44; 37 urines with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml were processed &#40;14 samples with counts between 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span>and 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; 17 samples with counts between 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; and six samples with counts &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#41;&#46; Additionally&#44; four samples with yeast were processed&#46; Briefly&#44; a total of 141 monomicrobial positive urine samples were processed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Working procedure</span><p id="par0035" class="elsevierStylePara elsevierViewall">In order to obtain direct identification&#44; the urine samples were processed as follows&#58; samples were homogenized by agitation&#44; and 5<span class="elsevierStyleHsp" style=""></span>ml was centrifuged for 5<span class="elsevierStyleHsp" style=""></span>min at 700<span class="elsevierStyleHsp" style=""></span>rpm&#46; The supernatant obtained was centrifuged for 15<span class="elsevierStyleHsp" style=""></span>min at 6000<span class="elsevierStyleHsp" style=""></span>rpm&#46; The sediment was resuspended in 1<span class="elsevierStyleHsp" style=""></span>ml of HPLC quality distilled water and was centrifuged again for 15<span class="elsevierStyleHsp" style=""></span>min at 6000<span class="elsevierStyleHsp" style=""></span>rpm&#46; The proteins of the sediment were extracted using the ethanol&#47;formic acid technique&#46; In order to carry out this extraction the sample was mixed with 300<span class="elsevierStyleHsp" style=""></span>&#956;l of HPLC quality distilled water and 900<span class="elsevierStyleHsp" style=""></span>&#956;l of absolute ethanol&#44; and vortexed until a homogeneous suspension was achieved&#46; The mixture was centrifuged for 2<span class="elsevierStyleHsp" style=""></span>min at 13&#44;000<span class="elsevierStyleHsp" style=""></span>rpm and the supernatant was eliminated&#46; Finally&#44; 25<span class="elsevierStyleHsp" style=""></span>&#956;l of 70&#37; formic acid and 25<span class="elsevierStyleHsp" style=""></span>&#956;l of acetonitrile were added&#44; vortexed and centrifuged for 1<span class="elsevierStyleHsp" style=""></span>min at 13&#44;000<span class="elsevierStyleHsp" style=""></span>rpm&#46; Using the supernatant obtained&#44; four 1<span class="elsevierStyleHsp" style=""></span>&#956;l spots were dropped on four different areas of the metal sample plate &#40;MSP 96 target polished steel&#59; Bruker&#44; Bremen&#44; Germany&#41;&#46; They were allowed to dry and 1<span class="elsevierStyleHsp" style=""></span>&#956;l of the matrix solution &#40;saturated solution of cyano-4-hydroxy cinnamic acid in 50&#37; acetonitrile with 2&#46;5&#37; trifluoroacetic acid&#41; was added to each spot to be analyzed&#46; They were allowed to dry again and then&#44; a reading of the four spots from each sample was taken&#46; All chemicals were supplied by Sigma&#8211;Aldrich &#40;St Louis&#44; MO&#44; USA&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Furthermore&#44; at the same time&#44; urine samples were plated&#44; using a calibrated loop so as to determine the number or CFU&#47;ml present in the urine&#44; on Columbia agar plates supplemented with 5&#37; sheep&#39;s blood &#40;bioM&#233;rieux&#44; Marcy l&#8217;Etoile&#44; France&#41; and MacConkey medium &#40;bioM&#233;rieux&#44; Marcy l&#8217;Etoile&#44; France&#41;&#59; in addition a Sabouraud<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Chloramphenicol agar plate &#40;Difco&#44; Maryland&#44; USA&#41; was added in those cases where fungal analysis was requested&#46; The plates were incubated at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;24<span class="elsevierStyleHsp" style=""></span>h in aerobic atmosphere and identification was done by MALDI technique&#46; Samples showing growth of two or more microorganisms were not included in the study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Protein analysis was carried out using a mass spectrometer MALDI Microflex LT &#40;BrukerDaltoniK GmbH&#44; Bremen&#44; Germany&#41; with FLexControl v&#46; 3&#46;0 software &#40;Bruker DaltoniK GmbH&#44; Bremen&#44; Germany&#41;&#46; The spectrum was obtained in linear mode &#40;N<span class="elsevierStyleInf">2</span> laser frequency and wavelength&#58; 60<span class="elsevierStyleHsp" style=""></span>Hz and 337<span class="elsevierStyleHsp" style=""></span>nm&#44; voltage of the ion source I&#58; 20<span class="elsevierStyleHsp" style=""></span>kV&#44; voltage of the ion source II&#58; 16&#46;7<span class="elsevierStyleHsp" style=""></span>kV&#59; detector mass range&#58; 2000&#8211;20&#44;137<span class="elsevierStyleHsp" style=""></span>Da&#41; and 240 shots from different positions of the metal sample plate were recorded&#46; Once the association is completed&#44; the Biotyper v&#46;3&#46;0 software &#40;Bruker DaltoniK GmbH&#44; Bremen&#44; Germany&#41; suggests a list of ten most likely microorganism identifications&#44; each with a score that indicates its accuracy<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; Adopting the manufacturer&#39;s criteria&#44; valid identifications may be deemed as those in which a score of &#8805;2&#46;000 is obtained for the first microorganism on the list&#46; The software also offered a consistency index&#44; which provides information concerning the quality of the identification that does not affect the validity of the results&#46; This consistency index depends on the concordance of the microbial identification obtained on the ten microorganisms on the list&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Results of the identification were interpreted in accordance with previously published criteria<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a>&#59; in those cases in which the criteria of the different authors were based on a single reading&#44; the first of the four replicates carried out was chosen and the remaining three replicates were rejected&#46; For this&#44; urine samples were divided into two subgroups&#44; one including the study group of 100 monobacterial samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; and another including the 37 urine samples with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#46; Moreover&#44; for each urine sample&#44; MALDI-TOF scores from direct sample and from colonies grown on plates were compared and&#44; taking the identification obtained by MALDI-TOF from culture using the criteria of the manufacturer as the gold standard&#44; a validation criterion for direct identification was defined&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In order to compare the identification results obtained using the different validation criteria&#44; the McNemar test was used&#46; In order to compare the frequency distribution in the population of the study group&#44; the Chi-squared test was used&#46; All these calculations were carried out using the SPSS software v&#46; 15&#46;0&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">No statistically significant difference was observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; when comparing isolates obtained from the study group with those from the University Clinic Hospital of Valladolid &#40;Spain&#41; during 2010 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Moreover&#44; the four species most frequently isolated in the urine samples from the Hospital were the same as those in the study group&#59; these were&#44; in order of greater to lesser prevalence&#44; <span class="elsevierStyleItalic">Escherichia coli</span> with isolate percentages of 56&#37; in the Hospital and 51&#37; in the study group&#44; <span class="elsevierStyleItalic">Enterococcus faecalis</span> with percentages of 18&#37; and 11&#37; respectively&#44; <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> with percentages of 7&#46;9&#37; and 11&#37; respectively and <span class="elsevierStyleItalic">Proteus mirabilis</span> with percentages of 4&#46;5&#37; and 4&#37; respectively&#46; Of the 100 urine samples that comprised the study group&#44; 63 were from women and 37 from men&#46; The age of the patients was between 4 and 94 years&#44; with an average age of 69 years&#59; and 23 of them were hospitalized&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml produced higher identification scores &#40;close to or above 2&#46;000&#41; in the majority of cases&#46; On the other hand&#44; the identification scores from urine with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml were lower&#44; such that identifications with scores &#60;1&#46;400 corresponded with microorganisms which are rarely etiological agents of urinary infection and&#44; in numerous occasions&#44; in one or more determinations of the four microorganisms carried out from the samples no peaks were obtained&#46; Moreover&#44; when scores were &#8805;1&#46;400&#44; despite the fact that the proposed microorganisms were included among the frequent UTIs source&#44; and the identification proposed for each spot was different&#44; the score was not a sufficient criterion for determining the identification of the bacteria&#44; given that&#44; in many cases&#44; the suggestion with a higher score did not coincide with the identification obtained from culture&#46; In this way&#44; we observed that taking as valid the identification that was repeated at least in two of the four spots with counts of &#8805;1&#46;400&#44; we obtained 100&#37; concordance in respect of the identifications carried out from culture&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Based on these data&#44; we proposed the following validation criterion&#58; a microorganism was correctly identified using MALDI-TOF when&#44; after having taken four readings of the same sample&#44; at least two readings offer the same identification proposal at species level for the first microorganism in the list&#44; both with a score of &#8805;1&#46;400&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Identification results obtained from all urine samples processed in accordance with the validation criteria adopted are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; When the identification results obtained from the study group by applying the criterion proposed in this study were compared with those obtained by applying the validation criteria of different authors<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a>&#44; no statistically significant differences were observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; On the other hand&#44; when the identification results from the 37 urine samples with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml by applying the criterion proposed in this study were compared&#44; we obtained statistically significant differences with respect to those obtained using the criteria of Moussaoui et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; Schubert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and Stevenson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; however&#44; no statistically significant differences were observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; with respect to the criterion of La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Bacterial identification results obtained by MALDI-TOF from 137 urine samples by applying the validation criterion proposed in this study are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Of the 51 samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml in which <span class="elsevierStyleItalic">E&#46; coli</span> was identified from culture&#44; there was only one failed identification from direct urine&#46; The eleven isolates of <span class="elsevierStyleItalic">K&#46; pneumoniae</span>&#44; the four of <span class="elsevierStyleItalic">P&#46; mirabilis</span> and <span class="elsevierStyleItalic">Klebsiella oxytoca</span>&#44; the three of <span class="elsevierStyleItalic">Citrobacter freundii</span>&#44; and the one of <span class="elsevierStyleItalic">Enterobacter aerogenes</span> and <span class="elsevierStyleItalic">Serratia marcescens</span> identified from culture were correctly identified from urine&#46; Finally&#44; of the two samples in which <span class="elsevierStyleItalic">Enterobacter cloacae</span> was isolated&#44; correct identification was obtained in one of them&#46; Of the four samples in which non-fermenting Gram-negative rods &#40;NFGNR&#41; were identified &#40;two urine samples with <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; one with <span class="elsevierStyleItalic">Acinetobacter baumannii</span> and one with <span class="elsevierStyleItalic">Acinetobacter genomospecies 3</span>&#41;&#44; there was only one failed identification&#44; which corresponded to a urine with <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#46; <span class="elsevierStyleItalic">Staphylococci</span> were isolated in four samples &#40;two urine samples with <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; one with <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> and one with <span class="elsevierStyleItalic">Staphylococcus saprophyticus</span>&#41;&#59; in this set of four samples&#44; only one correct direct identification was obtained&#44; which corresponded to one isolate of <span class="elsevierStyleItalic">S&#46; aureus</span>&#46; <span class="elsevierStyleItalic">E&#46; faecalis</span> was isolated from eleven samples&#44; and from ten of them correct identification was obtained from urine directly&#46; In the same way&#44; two correct identifications were obtained from a set of five samples with <span class="elsevierStyleItalic">Streptococcus agalactiae</span>&#46; In this way&#44; a 90&#37; sensitivity was obtained &#40;confidence interval of 95&#37;&#58; 81&#46;96&#8211;94&#46;84&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Of the 37 urine samples with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml direct identification was achieved in seven of them&#46; Of the 14 urine samples with counts between 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml there were ten with Gram-negative bacterial isolates&#44; and from these three correct identifications were obtained&#44; which were two isolates of <span class="elsevierStyleItalic">E&#46; coli</span> and one of <span class="elsevierStyleItalic">K&#46; pneumoniae</span>&#46; Three isolates of <span class="elsevierStyleItalic">E&#46; coli</span>&#44; one of <span class="elsevierStyleItalic">P&#46; mirabilis</span> and one of <span class="elsevierStyleItalic">Morganella morganii</span> were not identified from the sample directly&#46; On the other hand&#44; of the four samples with Gram-positive bacterial isolates &#40;two urines with an isolate of <span class="elsevierStyleItalic">E&#46; faecalis</span>&#44; one with <span class="elsevierStyleItalic">Enterococcus faecium</span> and one with <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#41; only one identification of <span class="elsevierStyleItalic">E&#46; faecalis</span> was obtained&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Of the 17 urine samples with counts between 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml there were 11 with Gram-negative bacterial isolates which provided three acceptable identifications of <span class="elsevierStyleItalic">E&#46; coli</span> from a direct sample&#59; three isolates of <span class="elsevierStyleItalic">E&#46; coli</span>&#44; two of <span class="elsevierStyleItalic">P&#46; mirabilis</span> and three of <span class="elsevierStyleItalic">P&#46; aeruginosa</span> were not identified&#46; In the six samples with Gram-positive bacterial isolates no correct identification was obtained&#46; In this case&#44; the strains identified from culture were one of <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; four of <span class="elsevierStyleItalic">E&#46; faecalis</span> and one of <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Of the six urine samples processed with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; no valid identification was obtained&#46; Five strains of <span class="elsevierStyleItalic">E&#46; coli</span> and one of <span class="elsevierStyleItalic">P&#46; mirabilis</span> were identified from culture&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As can be seen in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; as the bacterial concentration was reduced in the samples&#44; the percentages of identification and average scores obtained were also reduced&#46; For each urinary bacterial concentration&#44; the bacteria belonging to the family Enterobacteriaceae showed the greater percentage of correct identifications and higher average score&#44; and in the same way&#44; the percentage of correct identifications and the average score in Gram-negative bacteria were greater than that of Gram-positive bacteria&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the identification of yeasts by MALDI-TOF from four urine samples&#44; the species identified from culture was <span class="elsevierStyleItalic">Candida albicans</span>&#46; In the two urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml identification was obtained with an average score of 1&#46;989&#44; and in the two with counts between 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml no valid identification was obtained&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">This paper was focused on the direct microbial identification in urine samples regardless of their concentration because&#44; apart from the classic criterion described by Kass<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; it had demonstrated that counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml of bacteria and yeasts might be indicative of UTI in samples obtained through midstream clean catch<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The criteria for validation of results obtained using MALDI-TOF can be classified into two groups&#58; one takes into account the score and consistency index obtained in each reading and the other is based only on the score of the first microorganism in the list&#46; Belonging to the first group two proposals have been reported&#46; So&#44; Moussaoui et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> established that an identification is valid if a score of &#8805;1&#46;400 is obtained for the first microorganism in the list and the species in the first four identification proposals coincides&#59; similarly&#44; Schubert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> advocated that an identification is valid if a score of &#8805;1&#46;500 is obtained for the first microorganism and the species is the same in the first three identification proposals in the list&#46; Based on the score obtained for the first microorganism in the list given by the software&#44; two criteria can be found in the literature&#44; i&#46;e&#46;&#44; the one proposed by Stevenson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; and subsequently by Prod&#8217;hom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; Juiz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and Ferreira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#44; establishing that a score of &#8805;2&#46;000 in an identification indicates a species level identification&#44; a score between 1&#46;700 and 1&#46;900 indicates a genus level identification&#44; and a score of &#60;1&#46;700 indicates non-identification&#46; Finally&#44; the standard proposed by La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> established that a microorganism is identified correctly using MALDI-TOF when&#44; after having performed four identifications of a single sample&#44; the bacterial species with the highest score &#40;the first on the list&#41; coincides in all of them and a score of &#8805;1&#46;900 is obtained in at least two identifications&#44; or when a score of &#8805;1&#46;200 is obtained in the four identifications&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml of Gram-negative bacteria and <span class="elsevierStyleItalic">Enterococcus</span> spp&#46; provided high identification scores &#40;close to 2&#46;000&#41; and therefore high correct identification percentages were obtained&#44; regardless of the validation criteria used&#46; It is worth mentioning that the proposed criterion produced more direct identification percentages in the study group &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; However&#44; for the urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml of <span class="elsevierStyleItalic">Staphylococcus</span> spp&#46; or <span class="elsevierStyleItalic">Streptococcus</span> spp&#46; and urine with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; low identification scores &#40;close to 1&#46;400&#41; were obtained&#44; and as a consequence&#44; low identification percentages were obtained&#46; For these urine samples with low scores&#44; the identification percentage obtained depended on the criterion used in validating results and our criterion also produced higher percentages of correct direct identification &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The criteria of Moussaoui et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and Schubert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; which take into account the score and the consistency index&#44; were not suitable for the validation of these urine samples that provided low identification scores&#46; It was due to the lack of concordance at species level on the list of the ten microorganisms proposed by the software&#44; despite the fact that the first option in the list could coincide with the identification obtained from culture&#46; La Scola and Raoult<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; who used lower scores than all those published to date&#44; proposed substituting the consistency index obtained in a reading with the concordance at species level obtained in the first identification of the four readings carried out from the same sample&#59; which is to say&#44; this criterion is based on the score and the reproducibility of the equipment&#46; A limitation of this criterion consists in that proposing valid identification from scores of &#8805;1&#46;200 is not useful for validating of the results obtained from direct urine samples with low bacterial counts&#44; since we have observed that scores of &#60;1&#46;400 suggested microorganisms which are rarely etiological agents in UTI&#46; Using the criterion proposed in this study&#44; the higher identification score obtained in one of the four readings carried out from one sample was not a determining factor&#44; given that if an identification with a higher score than any other of those repeated was obtained&#44; this should be discarded&#46; So&#44; with the proposed criterion&#44; the weighting of the score was reduced in the validation of results&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">When 5<span class="elsevierStyleHsp" style=""></span>ml of urine with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml of <span class="elsevierStyleItalic">Staphylococcus</span> spp&#46; and <span class="elsevierStyleItalic">Streptococcus</span> spp&#46; or with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml was processed&#44; the bacterial concentration was insufficient for carrying out direct identification by MALDI-TOF from urine&#46; This suggested that in order to achieve the direct identification successfully it would be better to process greater sample volumes in order to process a greater amount of bacteria&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">No previous studies on direct identifications of yeasts from urine samples have been found in the literature&#46; Although the number of samples studied in which a yeast was isolated is very low&#44; the results obtained coincided with those from bacteria positive urine with regard to the microbial concentration in the sample&#59; which is to say&#44; the two strains of <span class="elsevierStyleItalic">C&#46; albicans</span> present in two urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml were correctly identified by applying our criterion and the two strains isolated in two samples with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml were not&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Results obtained in this study concur with those of Ferreira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and with those of Kohling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; which also observed that counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml produced higher percentage of direct identification in urine samples&#44; and that concentrations &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml produced low percentages of direct identification&#46; Our results also matched with those published by Christner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#44; who pointed out that with greater bacterial concentration in the sample&#44; greater is the quantity of microorganisms deposited on the metal sample plate and consequently a higher score was obtained&#46; In this way&#44; when the bacterial concentration in the urine sample is high &#40;&#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#41; satisfactory identification percentages are obtained&#44; above all in Gram-negative bacteria&#46; In urine with counts between 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml identification percentages were considerably reduced&#59; in urine with counts between 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml the percentages were reduced even further&#59; and in urine with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; no direct identification was achieved&#46; Moreover&#44; for each urine bacterial concentration the average score for Gram-negative bacteria obtained is superior to that of Gram-positive bacteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#59; these data coincides with that published by Schubert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who asserted that the MALDI-TOF system offers greater identification capacity for Gram-negative than Gram-positive bacteria&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">For performing bacterial identification directly from urine samples&#44; the clinician must request it in patients with suspected severe UTI&#46; Direct bacterial identification cannot be applied in all urine samples because they are those most commonly processed in clinical microbiology laboratories<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Direct identification is reported in less than one hour from the arrival of the urine to the laboratory and only includes the bacterial species present in urine&#46; For confirmation of direct identification and clinical significance&#44; it is necessary to perform bacterial identification and calculate bacterial counts from colonies obtained on isolation plates&#46; Therefore&#44; the clinician must assess clinical significance of direct bacterial identification and adopt appropriate measures regarding antimicrobial therapy&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A problem of direct identification by MALDI-TOF is that polymicrobial samples could provide wrong identifications since the spectra obtained include peaks of two or more microorganisms&#46; This problem has been partially solved with the use of software &#40;Bruker DaltoniK GmbH&#44; Bremen&#44; Germany&#41; which&#44; in some cases&#44; is able to report two bacterial identifications if both microorganisms are in correct proportions&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">To sum up&#44; applying the differential centrifugation protocol together with the validation criterion proposed in this study&#44; it was possible to achieve identification by MALDI-TOF of the microorganisms that most frequently cause UTI from direct monomicrobial urine samples with bacterial counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#59; and&#44; it was also possible to improve correct identifications in urine samples with bacterial counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Matrix assisted laser desorption&#47;ionization-time of flight &#40;MALDI-TOF&#41; mass spectrometry is widely established as a technique in clinical microbiology laboratories for the identification of microorganisms&#46; Using this technique&#44; it is also possible to obtain the identification of microorganisms from untreated urine samples&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this study&#44; a differential centrifugation protocol and a criterion for validation of the results in order to achieve microbial identification from untreated urine samples are proposed&#46; Additionally&#44; the sensitivity of the analytical procedure in monobacterial urine samples has been evaluated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 90&#37; sensitivity &#40;confidence interval of 81&#46;96&#37;&#8211;94&#46;84&#37;&#41; was obtained in urine samples with bacterial counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; and it was possible to improve the percentages of direct identifications from urine samples with bacterial counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">It is concluded that the MALDI-TOF system is both fast and reliable in the identification of individual microorganisms from untreated urine samples with counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El uso de la espectrometr&#237;a de masas Matrix Assisted Laser Desorption&#47;Ionization-Time of Flight &#40;MALDI-TOF&#41; es una t&#233;cnica implantada en los laboratorios de Microbiolog&#237;a Cl&#237;nica que permite llevar a cabo la identificaci&#243;n de microorganismos&#46; Una de las aplicaciones de esta t&#233;cnica es la identificaci&#243;n a partir de muestra directa de orina&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En este estudio se propone un protocolo de centrifugaci&#243;n diferencial y un criterio de validaci&#243;n de los resultados para alcanzar la identificaci&#243;n microbiana a partir de muestra directa de orina&#46; Adicionalmente se estudia la sensibilidad del procedimiento anal&#237;tico en muestras de orina monomicrobianas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las orinas con recuentos &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>UFC&#47;ml mostraron un 90&#37; de sensibilidad &#40;Intervalo de Confianza de 81&#46;96&#37;&#8211;94&#46;84&#37;&#41; y se logr&#243; mejorar los porcentajes de identificaci&#243;n directa a partir de orinas con recuentas bacterianos &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>UFC&#47;ml&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La espectrometr&#237;a de masas MALDI-TOF es un sistema r&#225;pido y fiable para la identificaci&#243;n de microorganismos a partir de orinas monomicrobianas con recuentos &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>UFC&#47;ml&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Positive urines year 2010 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3272&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study group &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>100&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Enterobacteriaceae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NFGNR<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Staphylococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Enterococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other microorganisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">NFGNR&#58; non-fermenting Gram-negative rods&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Results of identification obtained by MALDI-TOF from culture of positive urine samples from 2010 and from culture in the study group of 100 urine samples&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author &#40;reference&#41;&#44; kind of criterion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications in 100 urines that form the study group &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications in 37 urines with counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Moussaoui et al&#46;<span class="elsevierStyleSup">11</span>&#44; score and consistency index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Schubert et al&#46;<span class="elsevierStyleSup">12</span>&#44; score and consistency index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stevenson et al&#46;<span class="elsevierStyleSup">13</span>&#44; score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">La Scola and Raoult<span class="elsevierStyleSup">14</span>&#44; score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Criterion proposed&#44; score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Frequency of microorganisms identified by MALDI-TOF from 137 monobacterial urine samples related with the validation criterion adopted&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts of &#8805;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts between 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts between 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span> and 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Counts of &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications <span class="elsevierStyleItalic">n</span>&#47;<span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications <span class="elsevierStyleItalic">n</span>&#47;<span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications <span class="elsevierStyleItalic">n</span>&#47;<span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct identifications <span class="elsevierStyleItalic">n</span>&#47;<span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#47;80 &#40;96&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#47;10 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;650&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#47;11 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;6 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enterobacteriaceae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#47;76 &#40;97&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;070&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#47;8 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;650&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#47;8 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>NFGNR<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#47;4 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;809&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;2 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;3 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gram-positive bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#47;20 &#40;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;885&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#47;4 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;608&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;6 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#47;4 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;528&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">S&#46; agalactiae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#47;5 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;536&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;4 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enterococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#47;11 &#40;90&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;985&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#47;3 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;608&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#47;14 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;640&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;6 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2014.02.022

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Year/Month	Html	Pdf	Total

2024 November	6	1	7
2024 October	59	14	73
2024 September	53	11	64
2024 August	57	11	68
2024 July	59	7	66
2024 June	51	6	57
2024 May	50	17	67
2024 April	42	24	66
2024 March	62	8	70
2024 February	64	7	71
2024 January	90	15	105
2023 December	55	17	72
2023 November	66	34	100
2023 October	61	55	116
2023 September	45	34	79
2023 August	31	4	35
2023 July	30	27	57
2023 June	20	6	26
2023 May	21	6	27
2023 April	13	2	15
2023 March	26	5	31
2023 February	11	14	25
2023 January	10	13	23
2022 December	16	9	25
2022 November	26	36	62
2022 October	30	15	45
2022 September	23	14	37
2022 August	20	21	41
2022 July	18	23	41
2022 June	24	14	38
2022 May	32	16	48
2022 April	29	33	62
2022 March	17	17	34
2022 February	57	10	67
2022 January	37	6	43
2021 December	41	26	67
2021 November	34	13	47
2021 October	27	16	43
2021 September	17	7	24
2021 August	16	24	40
2021 July	25	19	44
2021 June	30	12	42
2021 May	17	8	25
2021 April	48	27	75
2021 March	18	11	29
2021 February	38	7	45
2021 January	38	11	49
2020 December	21	16	37
2020 November	14	19	33
2020 October	24	9	33
2020 September	35	12	47
2020 August	30	17	47
2020 July	33	8	41
2020 June	32	18	50
2020 May	26	21	47
2020 April	18	10	28
2020 March	26	12	38
2020 February	43	13	56
2020 January	26	15	41
2019 December	35	22	57
2019 November	19	16	35
2019 October	24	23	47
2019 September	20	18	38
2019 August	16	8	24
2019 July	35	26	61
2019 June	64	41	105
2019 May	148	102	250
2019 April	69	32	101
2019 March	15	11	26
2019 February	25	22	47
2019 January	28	15	43
2018 December	27	18	45
2018 November	38	19	57
2018 October	43	42	85
2018 September	22	4	26
2018 August	8	2	10
2018 July	9	3	12
2018 June	18	4	22
2018 May	29	8	37
2018 April	14	3	17
2018 March	15	0	15
2018 February	2	3	5
2018 January	9	10	19
2017 December	14	1	15
2017 November	17	4	21
2017 October	19	4	23
2017 September	11	4	15
2017 August	30	4	34
2017 July	12	5	17
2017 June	47	7	54
2017 May	38	12	50
2017 April	22	5	27
2017 March	26	26	52
2017 February	17	5	22
2017 January	16	2	18
2016 December	39	5	44
2016 November	65	12	77
2016 October	58	4	62
2016 September	43	14	57
2016 August	25	3	28
2016 July	38	3	41
2016 June	41	12	53
2016 May	26	1	27
2016 April	24	1	25
2016 March	26	12	38
2016 February	30	21	51
2016 January	30	22	52
2015 December	47	21	68
2015 November	27	18	45
2015 October	41	25	66
2015 September	43	30	73
2015 August	45	13	58
2015 July	37	13	50
2015 June	34	10	44
2015 May	77	24	101
2015 April	64	27	91
2015 March	66	71	137
2015 February	100	108	208

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