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Editorial
Coinfection and superinfection in SARS-CoV-2 pneumonia. Two underestimated threats. The need of empirical treatment under debate
Coinfección y superinfección en neumonía por SARS-CoV-2. Dos amenazas infraestimadas. La necesidad de tratamiento empírico a debate
Rafael Zaragoza Crespo
Corresponding author
zaragoza_raf@gva.es

Corresponding author.
, Héctor Hernández-Garcés
Intensive Care Unit, Hospital Universitario Dr. Peset, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Unfortunately&#44; infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia&#44; specially in critical care setting&#46; Furthermore&#44; these infections are associated themselves to and increased morbility and a worse prognosis without any doubt&#46; Moreover&#44; it is going without saying than some conditions such frequent development of organic failure requiring invasive supportive treatments&#44; poor immune status and prolonged ICU length of stay in saturated structural areas of patients are risk factors for nosocomial infection development&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue&#44; two interesting studies have been published in this field&#46; One of them<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> is related to the incidence of coinfections and superinfections of patients with severe SARS-CoV-2 pneumonia in a general hospital in Spain&#44; their clinical and microbiological features and their prognosis&#46; The second one<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> analyzes the influence of COVID infections in the rate of blood cultures extracted-including contamination ratio- &#40;before and after design&#41;&#44; and their etiology also in our country&#46; Both manuscripts actualize this relevant information and clearly resolve these important matters&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the first of them Nebreda-Mayoral et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> performed a retrospective observational study of all patients admitted for COVID-19 and bacterial&#47;fungal infections at the Hospital Cl&#237;nico Universitario of Valladolid in Spain during a period of three months in the first wave&#46; The authors included 712 COVID-19 patients &#40;44&#37; of them were admitted in ICU&#41;&#46; Sixteen of them presented bacterial&#47;fungal coinfections or superinfections&#46; Coinfections were diagnosed in 5&#37; whereas superinfections were detected in 11&#37;&#44; majority were admitted in ICU&#46; Most common pathogens of respiratory coinfection were <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;6&#41; and <span class="elsevierStyleItalic">Staphylococcus aureus</span> and urinary track infection was the main foci&#46; <span class="elsevierStyleItalic">Acinetobacter baumannii</span> multidrug-resistant was the main agent of superinfections due to an outbreak in ICU&#46; Only three patients were considered to have probable pulmonary aspergillosis&#46; The outbreak of <span class="elsevierStyleItalic">A&#46; baumannii</span> was a determining factor in the increases of the incidence of infection and the mortality of ICU patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">These data shows similarities and differences with other studies recently published&#46; As the authors comment&#44; the incidence of coinfection and superinfections depend on the population studied&#46; In this way Langford et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> evaluated the presence of bacterial coinfection in a large meta-analysis of over 3338 patients&#46; A total of 3&#46;5&#37; of the patients presented coinfection&#46; In contrast in relation to the critically ill setting&#44; the authors analyzed the data of 5 studies documenting coinfection in 14 out of a total of 144 patients &#40;9&#46;7&#37;&#41;&#46; In other large metanalysis published by Lansbury et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> described an higher number of coinfections in ICU patients than patients in mixed ward&#47;ICU settings &#40;14&#37; versus 4&#37;&#41;&#46; The etiology of coinfections in these two large metaanalysis<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#44;6</span></a> seems to be similar to those described in the manuscript from Valladollid<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> being <span class="elsevierStyleItalic">S&#46;pneumoniae</span>&#44; <span class="elsevierStyleItalic">S&#46;aureus</span> and <span class="elsevierStyleItalic">H&#46; influenzae</span> the most frequent isolated microorganisms&#46; As remarkable additional data the pooled proportion with a viral co-infection was 3&#37; described by Lansbury el al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> with Respiratory Syncytial Virus and influenza A the commonest&#46; These data have been also corroborated by a Spanish study performed in the first wave&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although A&#46; <span class="elsevierStyleItalic">baumanni</span> outbreaks<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> has been rarely reported during the pandemia in ICU as Nebreda-Mayoral et al do&#44; major differences are found when reviewing ICU nosocomial infection reported data&#44; specially about incidence and etiology&#46; The first data generated by the ENVIN-COVID registry<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> during the first wave including 1525 patients with COVID-19 admitted to intensive care&#44; showed that 50&#37; of the patients had suffered one or more infections&#44; with multiplied ratio between two- and four-fold for the infections under surveillance&#46; Two Spanish ICU<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#44;11</span></a> also have noticed an incidence of almost 52&#37; referred to infections acquired in the ICU&#46; Respiratory foci were the most common presentation and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> was the most frequently isolated microorganism in these last three studies instead of <span class="elsevierStyleItalic">A&#46; baumanni</span>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The role of difficult to treat microorganism has been also analyzed in ICU&#46; In a multicenter study carried out in 36 ICUs in Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> which included the same number of patients on mechanical ventilation per center with SARS-CoV-2 infection&#44; influenza infection or no viral infection&#44; the incidence of ventilator-associated tracheobronchitis and ventilator associated pneumonia was greater in the patients with SARS-CoV-2 than in the other two groups&#46; Gramnegative bacilli such as <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#44; <span class="elsevierStyleItalic">Enterobacter</span> spp&#46; and <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; were responsible for most of the episodes in all three study groups&#46; Surprisingly&#44; the percentage of patients with episodes involving multiresistant bacteria was lower in pneumonia due to SARS-CoV-2 than in the other two groups&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Nebreda-Mayoral study<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> failed to demonstrate an elevated incidence of <span class="elsevierStyleItalic">Aspergillus</span> infection in these patients&#44; however it is well known &#40;especially after the first wave&#41; that the incidence can reach in same studies at 30&#37;&#46; This is the reason&#44; among others&#44; to the development of CAPA &#40;COVID-19-associated pulmonary aspergillosis&#41; new definitions&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The relationship between the use of tocilizumab and increased rate of superinfections has not been resolved in the work from Valladolid either and its role remains controversial&#46; Somers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> evidenced that the use of tocilizumab in a cohort of 154 patients subjected to mechanical ventilation was associated to a greater proportion of superinfections &#40;54&#37; versus 26&#37;&#41; without any significant influence on mortality &#40;22&#37; vs 15&#37;&#41; being pneumonia &#40;45&#37;&#41; and bacteremia &#40;14&#37;&#41; the most frequent conditions&#46; However&#44; in the largest meta-analysis to date&#44; Tleyjeh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> found the use of tocilizumab to imply no higher nosocomial infection rate than in the control group&#46; A new well-designed study focused on superinfections in critically ill patients and the use of tocilizumab is warranted to resolve this controversy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the second manuscript<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> the authors investigated the rate and etiology of bacteremia and contaminated blood cultures collected from COVID and non-COVID patients&#46; They also performed a retrospective analysis in a tertiary hospital in Spain during the COVID first wave&#46; There were a 22&#46;7&#37; and 18&#46;8&#37; of decrease of number of blood cultures obtained compared to previous years&#46; However&#44; the rate of bacteremia was 1&#46;2&#37; higher among COVID-patients than among non-COVID patients&#46; COVID patients had a higher proportion of nosocomial bacteremia &#40;95&#46;5&#37;&#41; than non-COVID patients &#40;30&#46;5&#37;&#41; In COVID-positive patients&#44; the contamination rate was higher &#40;12&#46;3&#37; vs 5&#46;7&#37;&#41; than in non-COVID patients&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A large study performed in New York city<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> showed opposite results regarding the rates of bacteriemia found&#46; In this study this was significantly lower among COVID-19 patients &#40;3&#46;8&#37;&#41; than among COVID-19-negative patients &#40;8&#46;0&#37;&#41; and those not tested &#40;7&#46;1&#37;&#41;&#46; One possible explanation must be related with a minor rate of contamination because the proportion of positive blood cultures that yielded contaminants was also significantly higher among COVID-19 patients&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Two important facts must be noticed after reading this manuscript&#44; the first one is about the decreased number of blood cultures obtained&#46; We are sure this fact is due to the difficulty that isolation and physical barriers in COVID infection add to obtain samples&#46; The second one is related to the high proportion of blood culture contamination was identified&#44; especially in COVID-positive patients&#46; As the authors remarks It could be explained by unfamiliarity of additional personal protective equipment worn by healthcare workers taking blood cultures&#46; In contrast&#44; as Dagere S<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> et al&#46; recommends&#44; the accurate differentiation of a contaminant from a true pathogen relies on a multidisciplinary approach and the clinical judgement of experienced practitioners&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Finally&#44; after considering the results of the two studies published in this issue&#44; a debate arises about the need or not of empirical treatment in these two entities-coinfection and superinfections&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the case of coinfections certainly not as a general rule&#46; Following the recommendations of SEMICYUC<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> in critical care setting we should recommend early empirical treatment of possible bacterial pulmonary coinfection &#40;strong clinical suspicion&#44; purulent secretions&#44; biomarker elevation and&#47;or positive antigens&#41; upon admission to the ICU of patients with COVID-19&#44; since such coinfection is associated to increased mortality&#46; The early suspension of antimicrobial treatment once coinfection is ruled out must be a reality in clinical practice&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We also suggest an early diagnostic strategy and empirical treatment&#44; in view of the high risk of bacterial and fungal superinfection in patients with COVID-19 specially subjected to mechanical ventilation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mission of the clinician is to promote rational&#44; efficient and safe use of antibiotics&#44; by means of scientific evaluation and selection of the right antimicrobial for each patient based on criteria of effectiveness&#44; safety&#44; quality and efficiency&#44; based on risk factors and local flora&#46; Then we must hit at the first attempt with appropriate empirical treatment and after&#44; if possible&#44; deescalate&#46;</p></span>"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "&#193;&#46; Estella"
                            1 => "P&#46; Vidal-Cort&#233;s"
                            2 => "A&#46; Rodr&#237;guez"
                            3 => "D&#46; Andaluz Ojeda"
                            4 => "I&#46; Mart&#237;n-Loeches"
                            5 => "E&#46; D&#237;az"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medine.2021.08.013"
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Intensiva &#40;Engl Ed&#41;"
                        "fecha" => "2021"
                        "volumen" => "45"
                        "paginaInicial" => "485"
                        "paginaFinal" => "500"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characteristics and predictors of death among 4035 consecutively hospitalized patients with COVID-19 in Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Berenguer"
                            1 => "P&#46; Ryan"
                            2 => "J&#46; Rodr&#237;guez-Ba&#241;o"
                            3 => "I&#46; Jarr&#237;n"
                            4 => "J&#46; Carratal&#224;"
                            5 => "J&#46; Pach&#243;n"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmi.2020.07.024.3"
                      "Revista" => array:4 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2020"
                        "volumen" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32437954"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0105"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infecci&#243;n bacteriana&#47;f&#250;ngica en pacientes con COVID-19 ingresados en un hospital de tercer nivel de Castilla y Le&#243;n&#44; Espa&#241;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:1 [
                            0 => "T&#46; Nebreda-Mayoral"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2022"
                        "volumen" => "40"
                        "paginaInicial" => "158"
                        "paginaFinal" => "165"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0110"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bacteremia during COVID-19 pandemic in a tertiary hospital in Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:1 [
                            0 => "S&#46; Mormeneo Bayo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2022"
                        "volumen" => "40"
                        "paginaInicial" => "183"
                        "paginaFinal" => "186"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bacterial co-infection and secondary infection in patients with COVID-19&#58; a living rapid review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46;J&#46; Langford"
                            1 => "M&#46; So"
                            2 => "S&#46; Raybardhan"
                            3 => "V&#46; Leung"
                            4 => "D&#46; Westwood"
                            5 => "D&#46;R&#46; MacFadden"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmi.2020.07.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2020"
                        "volumen" => "26"
                        "paginaInicial" => "1622"
                        "paginaFinal" => "1629"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32711058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Co-infections in people with COVID-19&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Lansbury"
                            1 => "B&#46; Lim"
                            2 => "V&#46; Baskaran"
                            3 => "W&#46;S&#46; Lim"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2020.05.046.13"
                      "Revista" => array:4 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2020"
                        "volumen" => "81"
                        "paginaInicial" => "26675"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence of co-infections and superinfections in hospitalised patients with COVID-19&#58; a retrospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Garc&#237;a-Vidal"
                            1 => "G&#46; Sanjuan"
                            2 => "E&#46; Moreno-Garc&#237;a"
                            3 => "P&#46; Puerta-Alcalde"
                            4 => "N&#46; Garcia-Pouton"
                            5 => "M&#46; Chumbita"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmi.2020.07.041.5"
                      "Revista" => array:3 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2020"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11866852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic&#58; report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Thoma"
                            1 => "M&#46; Seneghini"
                            2 => "S&#46;N&#46; Seiffert"
                            3 => "D&#46; Vuichard Gysin"
                            4 => "G&#46; Scanferla"
                            5 => "S&#46; Haller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s13756-022-01052-8"
                      "Revista" => array:5 [
                        "tituloSerie" => "Antimicrob Resist Infect Control"
                        "fecha" => "2022"
                        "volumen" => "11"
                        "paginaInicial" => "12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35063032"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;SEMICYUC&#41;&#46; Grupo de Trabajo de Enfermedades Infecciosas y Sepsis &#40;GTEIS&#41;&#46; Estudio Nacional de Vigilancia de Infecci&#243;n Nosocomial&#46; ENVINCOVID 2020&#46; Available from&#58; <a target="_blank" href="https://hws.vhebron.net/envin-helics/">https&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;envin-helics&#47;</a>&#46;"
                ]
              ]
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            9 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low incidence of co-infection&#44; but high incidence of ICU-acquired infections in critically ill patients with COVID-19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;C&#46; Soriano"
                            1 => "C&#46; Vaquero"
                            2 => "A&#46; Ortiz-Fern&#225;ndez"
                            3 => "A&#46; Caballero"
                            4 => "A&#46; Blandino-Ortiz"
                            5 => "R&#46; de Pablo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2020.09.010"
                      "Revista" => array:2 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2020"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High rate of infections during ICU admission ofpatients with severe SARS-CoV-2 pneumonia&#58; a matter of time&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Barrasa"
                            1 => "A&#46; Mart&#237;n"
                            2 => "J&#46; Maynar"
                            3 => "J&#46; Rello"
                            4 => "M&#46; Fern&#225;ndez-Torres"
                            5 => "A&#46; Aguirre-Qui&#241;onero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2020.12.001"
                      "Revista" => array:2 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2020"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Rouz&#233; A&#44; Martin-Loeches I&#44; Povoa P&#44; Makris D&#44; Artigas A&#44; Bouchereau M&#44; et al&#46; Relationship between SARS-CoV-2 infection and the incidence of ventilator-associated lower respiratory tract infections&#58; a European multicenter cohort study&#46; Intensive Care Med&#46; 2021&#59;47&#58;188&#8211;98&#46; <a target="_blank" href="doi:10.1007/s00134-020-06323-9">doi&#58;10&#46;1007&#47;s00134-020-06323-9</a>&#46; Epub 2021 Jan 3&#46; Erratum in&#58; Intensive Care Med&#46; 2021 Nov 24&#59;&#58; PMID&#58; 33388794&#59; PMCID&#58; PMC7778569&#46;"
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Defining and managing COVID-19-associated pulmonary aspergillosis&#58; the 2020 ECMM&#47;ISHAM consensus criteria for research and clinical guidance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Koehler"
                            1 => "M&#46; Bassetti"
                            2 => "A&#46; Chakrabarti"
                            3 => "S&#46;C&#46;A&#46; Chen"
                            4 => "A&#46;L&#46; Colombo"
                            5 => "M&#46; Hoenigl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(20)30847-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2021"
                        "volumen" => "21"
                        "paginaInicial" => "e149"
                        "paginaFinal" => "e162"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33333012"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tocilizumab for treatment of mechanically ventilated patients with COVID-19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;C&#46; Somers"
                            1 => "G&#46;A&#46; Eschenauer"
                            2 => "J&#46;P&#46; Troost"
                            3 => "J&#46;L&#46; Golob"
                            4 => "T&#46;N&#46; Gandhi"
                            5 => "L&#46; Wang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciaa954"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2021"
                        "volumen" => "73"
                        "paginaInicial" => "e445"
                        "paginaFinal" => "e454"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32651997"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of tocilizumab in COVID-19 patients&#58; a living systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;M&#46; Tleyjeh"
                            1 => "Z&#46; Kashour"
                            2 => "M&#46; Damlaj"
                            3 => "M&#46; Riaz"
                            4 => "H&#46; Tlayjeh"
                            5 => "M&#46; Altannir"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmi.2020.10.036"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2021"
                        "volumen" => "27"
                        "paginaInicial" => "215"
                        "paginaFinal" => "227"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33161150"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bacteremia and blood culture utilization during COVID-19 surge in New York City"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Sepulveda"
                            1 => "L&#46;F&#46; Westblade"
                            2 => "S&#46; Whittier"
                            3 => "M&#46;J&#46; Satlin"
                            4 => "W&#46;G&#46; Greendyke"
                            5 => "J&#46;G&#46; Aaron"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/JCM.00875-20.5"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Clin Microbiol"
                        "fecha" => "2020"
                        "volumen" => "58"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contaminants in blood cultures&#58; importance&#44; implications&#44; interpretation and prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Darg&#232;re"
                            1 => "H&#46; Cormier"
                            2 => "R&#46; Verdon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cmi.2018.03.030"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2018"
                        "volumen" => "24"
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Article information
ISSN: 0213005X
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos