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Predominance of SCCmec types IV and V among biofilm producing device-associated Staphylococcus aureus strains isolated from tertiary care hospitals in Mysuru, India
Predominio de SCCmec tipos iv y v en las cepas de Staphylococcus aureus productoras de biopelículas aisladas de infecciones de dispositivos médicos en hospitales terciarios de Mysuru, India
Pradeep Halebeedu Prakash, Vineeth Rajan, Shubha Gopal
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Department of Studies in Microbiology, University of Mysore, Manasagangotri, Mysore, Karnataka, India
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"apellidos" => "Halebeedu Prakash" ] 1 => array:2 [ "nombre" => "Vineeth" "apellidos" => "Rajan" ] 2 => array:4 [ "nombre" => "Shubha" "apellidos" => "Gopal" "email" => array:1 [ 0 => "shubhagopal_mysore@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Studies in Microbiology, University of Mysore, Manasagangotri, Mysore, Karnataka, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Predominio de SCC<span class="elsevierStyleItalic">mec</span> tipos <span class="elsevierStyleSmallCaps">iv</span> y <span class="elsevierStyleSmallCaps">v</span> en las cepas de <span class="elsevierStyleItalic">Staphylococcus aureus</span> productoras de biopelículas aisladas de infecciones de dispositivos médicos en hospitales terciarios de Mysuru, India" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1499 "Ancho" => 1709 "Tamanyo" => 133806 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of biofilm positive strains and their respective strength.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Medical devices have been extensively used in health care; but they are known to promote bacterial adherence through biofilms. The contact of medical devices with the extracellular matrix proteins in patients, can trigger biofilm production and cause device-associated infections. <span class="elsevierStyleItalic">Staphylococcus aureus</span>, an important pathogen of community and hospital acquired infections, has been frequently reported to form biofilm on indwelling devices such as orthopaedic implants, urinary catheters, central venous catheters, peripheral venous catheters, endotracheal tubes, cardiac prosthetic valves, contact lens and on surgical sites.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Biofilms formed by <span class="elsevierStyleItalic">S. aureus</span> on orthopaedic implants are reportedly known to cause increased morbidity in patients when compared to the infection on other implants.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> But <span class="elsevierStyleItalic">S. aureus</span> biofilm on peripheral venous catheters (PVC) and central venous catheters (CVC) is also a major problem as it leads to blood stream infections.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> Tracheobronchial secretions in the intubated endotracheal tube acts as a sovereign risk factor for ventilator-associated pneumonia (VAP). These secretions promote <span class="elsevierStyleItalic">S. aureus</span> to form biofilm on the inner surface of endotracheal tube. Recent study on endotracheal tube mediated VAP has shown the prevalence of 22% of biofilm positive <span class="elsevierStyleItalic">S. aureus</span>.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">S. aureus</span> is also accounted for infective endocarditis in patients with cardiac prosthesis.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> A multi-national study comprising 1779 patients with infective endocarditis has shown high prevalence of 31.4% of <span class="elsevierStyleItalic">S. aureus</span> in these infections.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> Thus, the plethora of biofilm associated infections caused by <span class="elsevierStyleItalic">S. aureus</span> is unimaginable and surveillance studies to monitor the spread of <span class="elsevierStyleItalic">S. aureus</span> in hospitals are warranted.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Production of biofilm by <span class="elsevierStyleItalic">S. aureus</span> is primarily mediated by the intercellular adhesin operon (<span class="elsevierStyleItalic">ica</span> operon) which codes for the synthesis of polysaccharide intercellular adhesin (PIA).<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Biofilm can also be triggered by intercellular adhesion independent factors such as biofilm associated protein (Bap), clumping factor A and B (ClfA and ClfB), Fibronectin binding proteins A and B (FnBpA and FnBpB), <span class="elsevierStyleItalic">Staphylococcus aureus</span> surface protein A (Spa), cidAB, <span class="elsevierStyleItalic">Staphylococcus aureus</span> surface proteins G and C.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8–10</span></a> So based on the presence or absence of intercellular adhesion genes, biofilm promoting genes in <span class="elsevierStyleItalic">S. aureus</span> are broadly classified into <span class="elsevierStyleItalic">ica</span>-dependent and <span class="elsevierStyleItalic">ica</span>-independent factors.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Apart from biofilm production, upsurge in <span class="elsevierStyleItalic">S. aureus</span> infections is mainly due to the acquisition of resistance to antibiotics belonging to beta-lactam group.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> One such antibiotic is methicillin and the resistance to this antibiotic was reported within one year of its introduction. Methicillin Resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MRSA) has now emerged as a global pathogen in hospital- and community-associated infections. Like many other countries, even in India the prevalence of MRSA has been increased.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> Resistance to methicillin in <span class="elsevierStyleItalic">S. aureus</span> is mainly mediated by the <span class="elsevierStyleItalic">mecA</span> gene carried on a mobile genetic element staphylococcal cassette chromosome <span class="elsevierStyleItalic">mec</span> (SCC<span class="elsevierStyleItalic">mec</span>).<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> These are extremely diverse elements and based on the structural organization, they have been broadly classified into SCC<span class="elsevierStyleItalic">mec</span> type I to SCC<span class="elsevierStyleItalic">mec</span> XI.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> Recent studies have shown that, in clinical isolates, the presence or absence of <span class="elsevierStyleItalic">mec</span>A gene influences the expression of biofilm phenotype.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> Methicillin susceptible strains are known to show enhanced biofilm production by expressing PIA<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a>; whereas, methicillin resistant strains formed biofilm in an <span class="elsevierStyleItalic">ica</span>-independent manner by secreting surface proteins or by releasing extracellular DNA.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> These data indicates that there is an increasing need to study the occurrence of methicillin resistance in biofilm producing <span class="elsevierStyleItalic">S. aureus</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">MRSA are broadly classified into community associated-MRSA (CA-MRSA) and hospital associated-MRSA (HA-MRSA). A typical CA-MRSA strain will show heightened susceptibility to antimicrobial agents, except for antibiotics belonging to beta-lactam group. This suggests that most of the CA-MRSA strains carry SCC<span class="elsevierStyleItalic">mec</span> type IV and V as they consists of smaller genetic island when compared to SCC<span class="elsevierStyleItalic">mec</span> I–III which are mainly found in HA-MRSA strains.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> Recent study from our lab has also shown the emergence of CA-MRSA of sequence type (ST) 2371 as a major clone among the clinical isolates collected from a tertiary care hospital in Mysuru, India.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> These data clearly demonstrate the need for SCC<span class="elsevierStyleItalic">mec</span>-typing in device-associated <span class="elsevierStyleItalic">S. aureus</span>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Presence of Panton-Valentine Leukocidin (<span class="elsevierStyleItalic">pvl</span>) gene is considered as a marker for CA-MRSA strains.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> It is interesting to note that, <span class="elsevierStyleItalic">pvl</span> is less frequently reported in biofilm associated infections.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> Hence, screening of <span class="elsevierStyleItalic">pvl</span> gene in device-associated isolates is necessary.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The present study was carried with an objective to identify the distribution of SCC<span class="elsevierStyleItalic">mec</span> types, <span class="elsevierStyleItalic">spa</span> types, <span class="elsevierStyleItalic">pvl</span>, antibiotic resistance, biofilm production and co-occurrence of <span class="elsevierStyleItalic">ica</span>-dependent and independent factors in device associated isolates. To the best of our knowledge, this is the first prevalence report on device-associated infections from Mysuru city, India which has a population of 3,001,127.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Sample collection</span><p id="par0040" class="elsevierStylePara elsevierViewall">This is a cross-sectional study, wherein 200 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>200) clinical <span class="elsevierStyleItalic">S. aureus</span> strains isolated from infected implants over a period of one year (January 2014 to January 2015), were studied. These strains were obtained from the Department of Microbiology at Jagadguru Sri Shivarathreeswara (JSS) Medical Hospital and Krishnarajendra (KR) Hospital located in Mysuru, India. JSS medical hospital is a tertiary care centre with 1800 beds and it has 37 super-speciality units. The KR hospital, another tertiary care hospital in Mysuru, has 1330 bed capacity and has more than 20 super-speciality units. Initial confirmation of <span class="elsevierStyleItalic">S. aureus</span> was done by the hospital staff using coagulase test, mannitol fermentation test and DNAse test. Later, molecular confirmation of <span class="elsevierStyleItalic">S. aureus</span> up to species level was done by PCR using the reported primers.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> The American Association of Orthopaedic surgeons has classified orthopaedic prosthetic infections into four types: Type I – any two intraoperative cultures showing positive results, Type II – infection occurring within one month after surgery, Type III – infection in a working prosthesis caused by haematogenous seeding, Type IV – infection persisting in a patient for more than one month.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> So based on the types, strains were isolated from orthopaedic implants. Types of patients, clinical conditions and the samples used for the isolation of <span class="elsevierStyleItalic">S. aureus</span> are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Screening for biofilm production</span><p id="par0045" class="elsevierStylePara elsevierViewall">Biofilm screening by crystal violet method was performed using a modified protocol as described earlier.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> Single colony of the isolate was inoculated to 25<span class="elsevierStyleHsp" style=""></span>ml trypticase soy broth with 0.5% glucose (TSB<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.5% G) and incubated at 37<span class="elsevierStyleHsp" style=""></span>°C for 8–10<span class="elsevierStyleHsp" style=""></span>h until 0.5 OD is obtained. This culture was re-inoculated to fresh TSB<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.5% G and incubated for 3–4<span class="elsevierStyleHsp" style=""></span>h to get 0.03 OD. 200<span class="elsevierStyleHsp" style=""></span>μl of this culture was inoculated to 96 wells flat bottom microtitre plate in triplicate and incubated at 37<span class="elsevierStyleHsp" style=""></span>°C for 48<span class="elsevierStyleHsp" style=""></span>h. <span class="elsevierStyleItalic">Staphylococcus aureus</span> ATCC 35556 was used as positive control and 3 wells with TSB<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.5% G alone were kept as negative control. After incubation, plates were washed thrice with 0.15<span class="elsevierStyleHsp" style=""></span>M sterile PBS and stained with 0.1% crystal violet (HiMedia Labs, Mumbai, India) for 30<span class="elsevierStyleHsp" style=""></span>min at room temperature. Stained microtitre plates are washed thrice with sterile distilled water and dried in hot air oven at 45<span class="elsevierStyleHsp" style=""></span>°C. The bound dye was re-solubilised by adding 160<span class="elsevierStyleHsp" style=""></span>μl of 33% (v/v) glacial acetic acid to each well and kept for 30<span class="elsevierStyleHsp" style=""></span>minutes at room temperature. The re-solubilised dye was transferred to a new microtitre plate and OD was measured at 570<span class="elsevierStyleHsp" style=""></span>nm in a spectrophotometer (Thermo-Fischer Scientific). Based on the obtained OD values, quantification of biofilm strength was performed using the following formula.</p><p id="par0050" class="elsevierStylePara elsevierViewall">At first the cut off OD (OD<span class="elsevierStyleInf">c</span>) was calculated using the formula<elsevierMultimedia ident="eq0005"></elsevierMultimedia>The OD<span class="elsevierStyleInf">c</span> was compared with the OD of samples (OD<span class="elsevierStyleInf">s</span>) and the strength of biofilm production observed in each isolate was assessed using the following formula<elsevierMultimedia ident="eq0010"></elsevierMultimedia></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Antibiogram and MIC of biofilm positive isolates</span><p id="par0055" class="elsevierStylePara elsevierViewall">Kirby-Bauer agar disc diffusion method was performed to determine the antibiogram of device associated strains.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> Antibiotics used were cefoxitin, erythromycin, gentamicin, rifampicin, trimethoprim-sulphomethoxazole, tetracycline, clindamycin, linezolid and ciprofloxacin. The susceptibility to antibiotics was assessed as per the Clinical Laboratory Standard Institute (CLSI) guidelines.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> MIC for oxacillin was calculated by agar-dilution method and the results were interpreted as per the CLSI guidelines.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">SCC<span class="elsevierStyleItalic">mec</span>-typing</span><p id="par0060" class="elsevierStylePara elsevierViewall">MRSA isolates were screened for different <span class="elsevierStyleItalic">mec</span> types by multiplex PCR using the conditions as previously described.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Accuprime Taq DNA polymerase (Invitrogen, USA) was used for the multiplex-PCR. The control strains used for typing were <span class="elsevierStyleItalic">S. aureus</span> COL (type I), <span class="elsevierStyleItalic">S. aureus</span> BK2464 (type II), <span class="elsevierStyleItalic">S. aureus</span> ANS46 (type III), <span class="elsevierStyleItalic">S. aureus</span> MW2 (type IV), <span class="elsevierStyleItalic">S. aureus</span> WIS (type V) and <span class="elsevierStyleItalic">S. aureus</span> HDE288 (type VI).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Molecular screening of <span class="elsevierStyleItalic">pvl</span>, <span class="elsevierStyleItalic">ica</span>-dependent and independent factors</span><p id="par0065" class="elsevierStylePara elsevierViewall">Molecular screening of ica-dependent, <span class="elsevierStyleItalic">ica</span>-independent and <span class="elsevierStyleItalic">pvl</span>-<span class="elsevierStyleItalic">luk f/s</span> genes were done by PCR. DNA was isolated using QIAamp DNA mini kit (Qiagen Cat. No. 51306) and the isolated DNA was used for PCR. The reaction was carried out in a 25<span class="elsevierStyleHsp" style=""></span>μl microfuge tube containing 2<span class="elsevierStyleHsp" style=""></span>μl of DNA, 11<span class="elsevierStyleHsp" style=""></span>μl of 2X PCR master mix (Cat. No. Beta Midsci™) and 12<span class="elsevierStyleHsp" style=""></span>μl of distilled water. Primers used for the detection of <span class="elsevierStyleItalic">S. aureus</span>, <span class="elsevierStyleItalic">pvl</span>, <span class="elsevierStyleItalic">ica</span>-dependent and independent factors are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> with the respective annealing temperature and amplicon size. PCR programme was set with an initial denaturation at 94<span class="elsevierStyleHsp" style=""></span>°C for 5<span class="elsevierStyleHsp" style=""></span>min followed by 35 cycles of 30<span class="elsevierStyleHsp" style=""></span>s of denaturation at 94<span class="elsevierStyleHsp" style=""></span>°C, 30<span class="elsevierStyleHsp" style=""></span>s of annealing and 60<span class="elsevierStyleHsp" style=""></span>s of extension at 72<span class="elsevierStyleHsp" style=""></span>°C. Final extension at 72<span class="elsevierStyleHsp" style=""></span>°C for 10<span class="elsevierStyleHsp" style=""></span>min was set as the last step of PCR programme. PCR was carried out in Eppendorf Master Cycler. 10<span class="elsevierStyleHsp" style=""></span>μl of amplified PCR products along with 1<span class="elsevierStyleHsp" style=""></span>kb DNA marker were loaded on 1.5% agarose gel and electrophoresis was performed. Amplicons were analyzed by using a gel documentation system.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100"><span class="elsevierStyleItalic">spa</span> typing</span><p id="par0070" class="elsevierStylePara elsevierViewall">MRSA isolates were subjected to <span class="elsevierStyleItalic">Spa</span>-typing. The technique involves the sequencing of extremely variable X region in the staphylococcal protein A. Amplification of variable X region was performed using the primers described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Amplified products were sequenced and the <span class="elsevierStyleItalic">spa</span> types were identified using Bionumerics version 6 software (Applied maths, Belgium).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">MTT assay for the detection of antibiotic resistance in established biofilms</span><p id="par0075" class="elsevierStylePara elsevierViewall">To check the effect of antibiotics on established biofilms, all the strong biofilm producing strains were subjected to MTT (3-[4,5-dimethyl-2-thiazolyl]-2,5-diphenyl-2H-tetrazolium-bromide) assay. This was performed using the method described previously<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a> with minor modifications. Based on the CLSI guidelines, resistant break point concentration (RBC) for linezolid, vancomycin and rifampicin was used in the MTT assay. The RBC for linezolid was set as 8<span class="elsevierStyleHsp" style=""></span>μg/ml, Vancomycin 16<span class="elsevierStyleHsp" style=""></span>μg/ml and rifampicin 4<span class="elsevierStyleHsp" style=""></span>μg/ml. Biofilms established on 24 well plates were treated with respective antibiotics for 1, 3 and 5 days. After the antibiotic treatment, wells were emptied and washed thrice with sterile PBS. Then, 100<span class="elsevierStyleHsp" style=""></span>μl of PBS with 1% MTT solution was added and incubated for 2<span class="elsevierStyleHsp" style=""></span>h at 37<span class="elsevierStyleHsp" style=""></span>°C. Later MTT was replaced by 100<span class="elsevierStyleHsp" style=""></span>μl dimethylsulphoxide (DMSO) and incubated for 15<span class="elsevierStyleHsp" style=""></span>min at room temperature. Bacteria with an active electron transport system reduced the tetrazolium salt to a water-soluble purple formazan product. This product was quantified by measuring the OD at 560<span class="elsevierStyleHsp" style=""></span>nm in a microplate reader. The inhibitory effect of antibiotics (OD<span class="elsevierStyleInf">i</span>) on established biofilms was studied by finding the ratio of OD values in presence of antibiotics and in the absence of antibiotics (control) on 1st, 3rd and the 5th day<elsevierMultimedia ident="eq0015"></elsevierMultimedia>The average OD<span class="elsevierStyleInf">560</span> (OD of 1st day, 3rd day and 5th day) of antibiotic treatment was compared with the OD<span class="elsevierStyleInf">560</span> values of respective controls of 1st day, 3rd day and 5th day. This represented the average inhibitory effect of a respective antibiotic OD<span class="elsevierStyleInf">resistance</span> (OD<span class="elsevierStyleInf">r</span>). Decrease in OD<span class="elsevierStyleInf">r</span> value indicated greater biofilm inhibition by the respective antibiotic.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Prevalence of MRSA, molecular confirmation of <span class="elsevierStyleItalic">S. aureus</span> and screening of SCC<span class="elsevierStyleItalic">mec</span> types</span><p id="par0080" class="elsevierStylePara elsevierViewall">All the 200 device-associated isolates obtained from two hospitals were confirmed as <span class="elsevierStyleItalic">S. aureus</span> by PCR. High prevalence of SCC<span class="elsevierStyleItalic">mec</span> types IV and V was observed. Some of the strains were found to be non-typeable. The prevalence of MRSA and distribution of SCC<span class="elsevierStyleItalic">mec</span> types among device associated strains are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>A.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Screening for biofilm production</span><p id="par0085" class="elsevierStylePara elsevierViewall">Based on the crystal violet assay, high prevalence of strong biofilm producing strains was observed in orthopaedic implant associated isolates and the lowest was in the isolates from urinary catheters. Strength based characterization and number of strains isolated from infected devices are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Screening of <span class="elsevierStyleItalic">pvl</span> and biofilm regulating genes</span><p id="par0090" class="elsevierStylePara elsevierViewall">Biofilm regulating genes, <span class="elsevierStyleItalic">icaAD</span>, were predominantly found in strong biofilm producing strains. Whereas, <span class="elsevierStyleItalic">ica</span>-independent genes were mainly found in moderate and weak biofilm producers. <span class="elsevierStyleItalic">icaAD</span> alone was found mainly in orthopaedic implants (28%). Interestingly, co-occurrence of <span class="elsevierStyleItalic">ica</span>-dependent and independent factors was higher in orthopaedic implants and peripheral venous catheters. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>B describes the occurrence of <span class="elsevierStyleItalic">pvl</span>, <span class="elsevierStyleItalic">ica</span>-dependent and independent genes in biofilm positive strains.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Antibiotic susceptibility test</span><p id="par0095" class="elsevierStylePara elsevierViewall">Strains showing resistance to cefoxitin in disc diffusion method were identified as MRSA. These isolates were found to be multi-drug resistant and the percentage of isolates resistant to each antibiotic is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135"><span class="elsevierStyleItalic">spa</span> typing</span><p id="par0100" class="elsevierStylePara elsevierViewall">Overall 31 different <span class="elsevierStyleItalic">spa</span> types were identified among 200 device associated strains. <span class="elsevierStyleItalic">spa</span> type t852 and t657 were found to be higher among MRSA isolates. Strains with SCC<span class="elsevierStyleItalic">mec</span> type IV mainly belonged to <span class="elsevierStyleItalic">spa</span> type t852 and SCC<span class="elsevierStyleItalic">mec</span> type V belonged to t657. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>C describes the distribution of <span class="elsevierStyleItalic">spa</span> types among the device associated strains.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Detection of antibiotic resistance in established biofilms</span><p id="par0105" class="elsevierStylePara elsevierViewall">Vancomycin and linezolid at a concentration of 16<span class="elsevierStyleHsp" style=""></span>μg/ml and 8<span class="elsevierStyleHsp" style=""></span>μg/ml respectively, were effective in inhibiting established strong biofilms (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Among 48 strong biofilm producers, these two antibiotics controlled biofilm production in 33 strains. But in remaining 9 strains, the inhibitory effect of these antibiotics was less. These strains, possessed both <span class="elsevierStyleItalic">icaAD</span> (<span class="elsevierStyleItalic">ica</span>-dependent) and all the <span class="elsevierStyleItalic">ica</span>-independent factors (<span class="elsevierStyleItalic">fnbpA</span>, <span class="elsevierStyleItalic">fnBpB</span>, <span class="elsevierStyleItalic">cidA</span>, <span class="elsevierStyleItalic">clfA</span>, <span class="elsevierStyleItalic">clfB</span> and <span class="elsevierStyleItalic">sasG</span>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">This is a first report on the prevalence and molecular profiling of device-associated <span class="elsevierStyleItalic">S. aureus</span> infections from Mysuru, India. Prevalence of device-associated infections was exceptionally high in isolates obtained from orthopaedic implants and peripheral venous catheters. In the present study, isolates from orthopaedic implants were able to form strong biofilms. This data suggests the increased risk of infections on orthopaedic implants through biofilm formation. Among the four types of orthopaedic implant associated infections, highest prevalence was observed in type I (9.5%) and type II (9.5%). The increased prevalence of orthopaedic device-associated infections, especially in type I and type II, warrants the need for proper hygiene practice during surgery.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Prevalence of peripheral venous catheter infections caused by <span class="elsevierStyleItalic">S. aureus</span> was moderate and the majority of strains showed weak biofilm phenotype. This could be due to their low duration of implantation. But some strains demonstrated strong biofilm phenotype, which foresee the essential role of <span class="elsevierStyleItalic">S. aureus</span> in PVC-associated infections. Device-associated infections were not limited to orthopaedic and peripheral venous catheters but were also observed in urinary catheters, central venous catheters and cardiac prosthesis. Their prevalence was comparatively low and they exhibited strong, moderate and weak biofilm phenotype.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Strains were further characterized for antibiotic susceptibility, SCC<span class="elsevierStyleItalic">mec</span> types, <span class="elsevierStyleItalic">pvl</span>, <span class="elsevierStyleItalic">spa</span>-types and biofilm regulating genes. The majority of isolated strains were resistant to methicillin (72.5%) and erythromycin (57%). Interestingly, resistance to gentamicin, clindamycin, rifampicin and tetracycline was mainly observed in the strains isolated from orthopaedic implants, cardiac prosthesis and peripheral venous catheters.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Minimal Inhibitory Concentration ≥256<span class="elsevierStyleHsp" style=""></span>μg/ml for oxacillin was observed in 105 (52.5%) strains. This high occurrence of extremely resistant MRSA strains in device-associated infections is alarming and thus screening for SCC<span class="elsevierStyleItalic">mec</span> types was performed. The recent trend in the epidemiology of CA-MRSA has shown the increased infiltration of these strains to hospitals.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> In the present study, high prevalence of SCC<span class="elsevierStyleItalic">mec</span> type IV (20.5%) and V (12%) among device-associated strains was observed. This could be due to the possible persistence of CA-MRSA strains in these hospitals. Occurrence of <span class="elsevierStyleItalic">pvl</span> in clinical strains is a useful marker to identify CA-MRSA strains. Thus, <span class="elsevierStyleItalic">pvl</span> screening for all the MRSA isolates was performed and it was found in 38 SCC<span class="elsevierStyleItalic">mec</span> type IV and 34 SCC<span class="elsevierStyleItalic">mec</span> type V strains. This increased occurrence of <span class="elsevierStyleItalic">pvl</span> and SCC<span class="elsevierStyleItalic">mec</span> type IV and V, suggests the possible intrusion of CA-MRSA strains in hospitals.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The diversity of <span class="elsevierStyleItalic">S. aureus</span> strains in device-associated infections, was studied by <span class="elsevierStyleItalic">spa</span>-typing for MRSA isolates. <span class="elsevierStyleItalic">spa</span> types t852 and t657 were frequently observed in SCC<span class="elsevierStyleItalic">mec</span> types IV and V. Strains with SCC<span class="elsevierStyleItalic">mec</span> types I, II, III and VI mainly displayed t307, t018 and t363, t172 <span class="elsevierStyleItalic">Spa</span> types respectively. <span class="elsevierStyleItalic">spa</span> types t018, t852 and t657 are reported to belong to the clonal complex CC30, CC22 and CC1 respectively.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> A recent study from Bangalore, south India, also showed the occurrence of t852, t3387 and t657 <span class="elsevierStyleItalic">spa</span> types in CA-MRSA strains.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> This clearly indicates the distribution of these <span class="elsevierStyleItalic">spa</span> types in this geographical region.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Numerous predisposing factors have been identified in the formation of biofilm on device-associated infections. One such factor is the implant itself. But biofilm on an implant can also be interceded by the duration of implantation, patient's health condition, antibiotic therapy and the presence or absence of biofilm regulating genes. In this context, biofilm positive strains (MRSA and MSSA) were characterized for the presence or absence of intercellular adhesion-dependent and independent genes. High prevalence of <span class="elsevierStyleItalic">ica</span>AD was observed in device-associated strains (32.5%) mainly in orthopaedic implants, peripheral venous catheters and cardiac prosthesis. The presence of <span class="elsevierStyleItalic">mecA</span> gene and the occurrence of <span class="elsevierStyleItalic">icaAD</span> was compared in device associated isolates. Interestingly 20 MSSA strains (27.5%) possessed <span class="elsevierStyleItalic">icaAD</span> genes and revealed strong biofilm phenotype. Previous studies have established an important relationship between the expressions of <span class="elsevierStyleItalic">icaAD</span> in the absence of <span class="elsevierStyleItalic">mecA</span> gene.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16,17</span></a> Thus, the current findings are in concordance with previous reports and it signifies the essential role of MSSA strains in device associated infections. In contrast to this observation, a recent study has shown that the excision of <span class="elsevierStyleItalic">mecA</span> gene in MRSA strain BH1CC, reduced the expression of FnBp proteins.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> This suggests the relation between <span class="elsevierStyleItalic">mec</span>A and FnBp proteins in biofilm expansion. In the present study an increased prevalence of <span class="elsevierStyleItalic">fnbpA</span> (19.5%) was identified in biofilm positive MRSA strains which substantiates the essential role of FnBpA in device-associated infections. Among the other <span class="elsevierStyleItalic">ica</span>-independent factors, the prevalence of <span class="elsevierStyleItalic">sasG</span> (23.5%) and <span class="elsevierStyleItalic">clfB</span> (18.5%) was high. Recent study has shown the mechanistic interaction of <span class="elsevierStyleItalic">S. aureus</span> SasG with <span class="elsevierStyleItalic">S. epidermidis</span> accumulation associated protein (Aap) through zinc ions.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> Thus, the presence of SasG in device-associated strains may favour <span class="elsevierStyleItalic">S. epidermidis</span> infections through mixed-biofilm formation on medical implants.</p><p id="par0140" class="elsevierStylePara elsevierViewall">MTT assay revealed the increased ability of some <span class="elsevierStyleItalic">S. aureus</span> strains to tolerate the effect of antibiotics. But the majority of strains were susceptible to linezolid and vancomycin; they showed their highest activity on the 5<span class="elsevierStyleSup">th</span> day of treatment. Among the screened isolates, vancomycin, linezolid and rifampicin were could not remove biofilms in 9 isolates. Further analysis revealed that these isolates possessed <span class="elsevierStyleItalic">ica</span>-dependent and independent factors. This would have favoured their increased resistance to the tested antibiotics.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion, our study on device-associated infections in two major hospitals in Mysuru, showed a high rate of multidrug resistant CA-MRSA strains. This underscores the need for routine surveillance of device-associated strains for implementing infection control strategies through proper antibiotic stewardship. Since medical implants promote biofilm formation, care must be taken while using these devices for patients’ treatment. Our study warrants the need for effective guidelines to control <span class="elsevierStyleItalic">S. aureus</span> infections in patients with medical implants.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">Pradeep HP thanks Indian Council of Medical Research for the award of Senior Research Fellowship (ICMR award letter No. 80/763/2012-ECD-I dated 02.04.2013).</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres827765" "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" => "xpalclavsec824079" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres827764" "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" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec824080" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Sample collection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Screening for biofilm production" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Antibiogram and MIC of biofilm positive isolates" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "SCCmec-typing" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Molecular screening of pvl, ica-dependent and independent factors" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "spa typing" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "MTT assay for the detection of antibiotic resistance in established biofilms" ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Prevalence of MRSA, molecular confirmation of S. aureus and screening of SCCmec types" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Screening for biofilm production" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Screening of pvl and biofilm regulating genes" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Antibiotic susceptibility test" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "spa typing" ] 5 => array:2 [ "identificador" => "sec0080" "titulo" => "Detection of antibiotic resistance in established biofilms" ] ] ] 7 => array:2 [ "identificador" => "sec0085" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack277733" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-15" "fechaAceptado" => "2016-09-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec824079" "palabras" => array:8 [ 0 => "Multi-drug resistance" 1 => "Biofilm" 2 => "<span class="elsevierStyleItalic">Staphylococcus</span>" 3 => "MRSA" 4 => "<span class="elsevierStyleItalic">ica</span>-dependent" 5 => "<span class="elsevierStyleItalic">ica</span>-independent" 6 => "<span class="elsevierStyleItalic">spa</span>-typing" 7 => "SCC<span class="elsevierStyleItalic">mec</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec824080" "palabras" => array:8 [ 0 => "Multirresistencia antibiótica" 1 => "Biopelícula" 2 => "<span class="elsevierStyleItalic">Staphylococcus</span>" 3 => "SARM" 4 => "<span class="elsevierStyleItalic">ica</span> dependiente" 5 => "<span class="elsevierStyleItalic">ica</span> independiente" 6 => "tipos <span class="elsevierStyleItalic">spa</span>" 7 => "SCC<span class="elsevierStyleItalic">mec</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Device associated infections caused by <span class="elsevierStyleItalic">Staphylococcus aureus</span> in hospitalised patients is a serious healthcare problem. The present study was designed to determine the prevalence of biofilm-producing MRSA in device-associated infections.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Device-associated <span class="elsevierStyleItalic">S. aureus</span> strains (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>200) obtained from two tertiary care hospitals in Mysuru city, India were screened for biofilm production, antibiotic resistance, Panton-Valentine Leucocidin genes, SCC<span class="elsevierStyleItalic">mec</span>-types, <span class="elsevierStyleItalic">spa</span>-types, and intercellular adhesion (<span class="elsevierStyleItalic">icaAD</span>) dependent and independent genes. The efficacy of antibiotics (linezolid, vancomycin and rifampicin) on biofilms was studied using MTT assay, and the results were correlated with the occurrence of <span class="elsevierStyleItalic">ica</span>-dependent and independent factors.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Multidrug resistance was observed in 155 strains (77.5%), and 124 strains (62%) were identified as biofilm producers. Methicillin resistance was identified in 145 strains (72.5%), and SCC<span class="elsevierStyleItalic">mec</span> typing of these isolates revealed high prevalence of type IV and type V. They also showed increased prevalence of <span class="elsevierStyleItalic">pvl</span> gene. <span class="elsevierStyleItalic">icaAD</span> was identified in 65 isolates, with 37 isolates showing both <span class="elsevierStyleItalic">icaAD</span> and <span class="elsevierStyleItalic">ica</span>-independent genes. <span class="elsevierStyleItalic">spa</span> types t852 and t657 were predominantly observed in MRSA isolates. Those isolates that had both <span class="elsevierStyleItalic">ica</span>-dependent and <span class="elsevierStyleItalic">ica</span>-independent genes showed more resistance to the screened antibiotics than the <span class="elsevierStyleItalic">ica</span>-dependent alone.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study reports a high prevalence of SCC<span class="elsevierStyleItalic">mec</span> type IV and V in biofilm producing <span class="elsevierStyleItalic">S. aureus</span> strains isolated from device-associated infections. Increased prevalence of <span class="elsevierStyleItalic">pvl</span> in SCC<span class="elsevierStyleItalic">mec</span> types IV and V strains suggests the role of community associated <span class="elsevierStyleItalic">S. aureus</span> in device-associated infections. The simultaneous presence of <span class="elsevierStyleItalic">ica</span>-dependent and independent genes increased the antibiotic resistance in established biofilms. Thus, <span class="elsevierStyleItalic">S. aureus</span> on medical devices is a potential risk for patients.</p></span>" "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" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las infecciones asociadas a dispositivos médicos causadas por <span class="elsevierStyleItalic">Staphylococcus aureus</span> en pacientes hospitalizados son un problema importante. En el presente trabajo se estudia, en cepas de infecciones asociadas a dispositivos médicos, la prevalencia SARM productores de biopelículas y sus tipos SCC<span class="elsevierStyleItalic">mec</span>.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se usaron 200 cepas de <span class="elsevierStyleItalic">S. aureus</span> de infecciones de dispositivos médicos obtenidas de 2 hospitales terciarios de Mysuru, India. Se estudió la producción de biopelículas, los genes de la leucocidina de Panton-Valentine, los tipos SCC<span class="elsevierStyleItalic">mec</span>, los tipos de <span class="elsevierStyleItalic">spa</span> y los genes de adhesión intracelular (<span class="elsevierStyleItalic">icaAD</span>) dependientes e independientes. Se estudió la eficacia de linezolid, vancomicina y rifampicina en las biopelículas por un ensayo MTT y los resultados se correlacionaron con la presencia de genes <span class="elsevierStyleItalic">ica</span> dependientes e independientes.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ciento veinticuatro cepas (62%) producían biopelículas y se observó multirresistencia antibiótica en 155 (77,5%). Eran resistentes a meticilina 145 cepas (72,5%) y en su tipificación SCC<span class="elsevierStyleItalic">mec</span> se observó alta prevalencia de los tipos <span class="elsevierStyleSmallCaps">iv</span> y <span class="elsevierStyleSmallCaps">v</span>. Estas cepas tenían una prevalencia superior de gen <span class="elsevierStyleItalic">pvl</span> a las no resistentes a meticilina. <span class="elsevierStyleItalic">icaAD</span> se identificó en 65 aislados, de los que 37 mostraron simultáneamente genes <span class="elsevierStyleItalic">ica</span> dependientes e independientes. Los spa tipos t852 y t657 se observaron predominantemente en las cepas de SARM. Los aislados que tenían a la vez genes <span class="elsevierStyleItalic">ica</span> dependientes e <span class="elsevierStyleItalic">ica</span> independientes presentaban mayor resistencia a los antibióticos probados que los que tenían solo <span class="elsevierStyleItalic">ica</span> dependientes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El presente estudio informa de una alta prevalencia de SARM de los SCC<span class="elsevierStyleItalic">mec</span> tipos <span class="elsevierStyleSmallCaps">iv</span> y <span class="elsevierStyleSmallCaps">v</span> en cepas de <span class="elsevierStyleItalic">S. aureus</span> productoras de biopelículas. La elevada prevalencia del gen <span class="elsevierStyleItalic">pvl</span> en las cepas de los SCCmec IV y V sugiere el papel de los <span class="elsevierStyleItalic">S. aureus</span> comunitarios en las infecciones asociadas a estos dispositivos. La presencia simultánea de genes <span class="elsevierStyleItalic">ica</span> dependientes e independientes aumenta la resistencia a antibióticos en las biopelículas establecidas. Por todo ello, las cepas de <span class="elsevierStyleItalic">S. aureus</span> en dispositivos médicos son un riesgo potencial para los pacientes.</p></span>" "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" => "Conclusión" ] ] ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1499 "Ancho" => 1709 "Tamanyo" => 133806 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of biofilm positive strains and their respective strength.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 823 "Ancho" => 1656 "Tamanyo" => 91524 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage resistance of antibiotics in device associated strains.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1347 "Ancho" => 1646 "Tamanyo" => 116003 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">MTT assay showing increased anti-biofilm effect by linezolid and vancomycin.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "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">Patient type \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">Implants used for patients’ treatment \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">Clinical symptoms \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">Samples used for the isolation of <span class="elsevierStyleItalic">S. aureus</span> \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">Number of strains isolated (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>200) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with fracture of tibia, knee, intertrochanteric fracture, diaphyseal fracture of femur \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients were treated with orthopaedic implants such as intramedullary nail, dynamic hip screw interlocking nail, stainless steel wire, locking plate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever, chills, redness around the knee joint, pus discharge and pain in the operated site \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swabs from orthopaedic implants and pus discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (28%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Patients in intensive care units</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Endotracheal tube</td><td class="td" title="table-entry " align="left" valign="top">Fever, chills and septicemia within five days of hospitalization (early onset) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tip of endotracheal tube \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever, chills and septicemia after five days of hospitalization (late onset) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tracheobronchial secretions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (3.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-operative patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urinary catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Catheter tip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (16%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients in intensive cardiac care units and on ventilators \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Central venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Catheter tip, blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (16%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New born babies in neonatal intensive care units and patients with severe hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Catheter tip, blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (18%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with open heart and by-pass surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cardiac prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swabs from mechanical heart valves, stents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (11%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392766.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Types of patients, clinical conditions and samples used for the isolation of <span class="elsevierStyleItalic">S. aureus</span>.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "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">Primer name \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">Primer sequence \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">Annealing temperature \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">Amplicon size in bp \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">Reference \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SA442 – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AAT CTT TGT CGG TAC ACG ATA TTC TTC ACG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">55</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">108</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0305">23</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SA442 – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CGT AAT GAG ATT TCA GTA GAT AAT ACA ACA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">icaAD</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CCT AAC TAA CGA AAG GTA GG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">55</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">1267</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0335">29</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">icaAD</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TTA GCG TTG GGT ATT CCC TC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">clfA</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ATT GGC GTG GCT TCA GTG CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">55</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">292</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0335">29</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">clfA</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CGT TTC TTC CGT AGT TGC ATT TG \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">clfB</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACA TCA GTA ATA GTA GGG GGC AAC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">55</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">205</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0335">29</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">clfB</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TTC GCA CTG TTT GTG TTT GCA C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">fnbpA</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAT AAA TTG GGA GCA GCA TCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">50</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">127</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0340">30</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">fnbpA</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ATC AGC AGC TGA ATT CCC ATT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">fnbpB</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GTA ACA GCT AAT GGT CGA ATT GAT ACT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">55</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">524</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0340">30</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">fnbpB</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAA GTT CGA TAG GAG TAC TAT GTT C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">sasG</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GTC AGT CAC TCA TAA CGC AGA G \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">50</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">400</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">This study</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">sasG</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CCC AAG GAT TCC ACC ATT AGT T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">cidA</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CCG GCA GTA TTG TTG GTC TAT T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">50</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">280</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">This study</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">cidA</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GCG TCT ACA CCT TTA CGA TGT T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">pvl</span> – <span class="elsevierStyleItalic">luk f/s</span> – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ATC ATT AGG TAA AAT GTC TGG ACA TGA TCC A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">52</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">433</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0345">31</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">pvl</span> – <span class="elsevierStyleItalic">luk f/s</span> – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GCA TCA AGT GTA TTG GAT AGC AAA AGC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">spa</span>-1113 – F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAA AGA CGA TCC TTC GGT GAG C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">59</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Variable</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0350">32</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">spa</span>-1514 – R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAG CAG TAG TGC CGT TTG CTT \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392765.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Primer sequence, annealing temperature and amplicon size used for molecular characterization.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:3 [ 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 " colspan="13" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">A: Prevalence of MRSA isolates and SCC<span class="elsevierStyleItalic">mec</span> types</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infected implant \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">Infection type/clinical symptoms \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">Number of strains isolated \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">Number of MRSA isolates \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">Isolates with MIC<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>256<span class="elsevierStyleHsp" style=""></span>μg/ml for oxacillin \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"><span class="elsevierStyleItalic">mecA</span> \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">SCC<span class="elsevierStyleItalic">mec</span> Type I \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">SCC<span class="elsevierStyleItalic">mec</span> Type II \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">SCC<span class="elsevierStyleItalic">mec</span> Type III \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">SCC<span class="elsevierStyleItalic">mec</span> Type IV \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">SCC<span class="elsevierStyleItalic">mec</span> Type V \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">SCC<span class="elsevierStyleItalic">mec</span> Type VI \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">Non typeable \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 " rowspan="4" align="left" valign="top">Orthopaedic implants</td><td class="td" title="table-entry " align="left" valign="top">Type I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \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><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">3 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \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><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">0 \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><td class="td" title="table-entry " align="char" valign="top">0 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Endotracheal tube</td><td class="td" title="table-entry " align="left" valign="top">Early onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (2.5%) \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><td class="td" title="table-entry " align="char" valign="top">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><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Late onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (3.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \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><td class="td" title="table-entry " align="char" valign="top">0 \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><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (16%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \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><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (16%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (15%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">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><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (18%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \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><td class="td" title="table-entry " align="char" valign="top">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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiac prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever with septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (11%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (9.5%) \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><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="13" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Total</td><td class="td" title="table-entry " align="char" valign="top">200 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>200) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 (72.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105 (52.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 (70%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (8.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (20.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (13.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392762.png" ] ] 1 => 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 " colspan="12" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B: Prevalence of biofilm regulating genes and PVL</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infected implant \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">Number of biofilm positive isolates \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"><span class="elsevierStyleItalic">icaAD</span> \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"><span class="elsevierStyleItalic">clfA</span> \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"><span class="elsevierStyleItalic">clfB</span> \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"><span class="elsevierStyleItalic">fnbpA</span> \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"><span class="elsevierStyleItalic">fnbpB</span> \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"><span class="elsevierStyleItalic">sasG</span> \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"><span class="elsevierStyleItalic">cidA</span> \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"><span class="elsevierStyleItalic">pvl</span><span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SCC<span class="elsevierStyleItalic">mec</span> type IV \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"><span class="elsevierStyleItalic">pvl</span><span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SCC<span class="elsevierStyleItalic">mec</span> type V \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"><span class="elsevierStyleItalic">pvl</span><span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SCC<span class="elsevierStyleItalic">mec</span> type I–III \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Orthopaedic implants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (28%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \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><td class="td" title="table-entry " align="char" valign="top">13 \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><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endotracheal tube \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (4.5%) \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><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \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><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (2.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">1 \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><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (8.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral venous catheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \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><td class="td" title="table-entry " align="char" valign="top">10 \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><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiac prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \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><td class="td" title="table-entry " align="char" valign="top">3 \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><td class="td" title="table-entry " align="char" valign="top">7 \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><tr title="table-row"><td class="td" title="table-entry " colspan="12" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " 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">124 (62%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (32.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (14%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (18.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (19.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (14.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (23.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (11.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (19%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (17%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (2.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392763.png" ] ] 2 => 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 " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">C: Diversity of <span class="elsevierStyleItalic">Spa</span>-types among device associated MRSA strains</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SCC<span class="elsevierStyleItalic">mec</span> types \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">Number of screened isolates \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">Frequently reported <span class="elsevierStyleItalic">spa</span> types \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">Number of frequently reported <span class="elsevierStyleItalic">spa</span> types \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t307 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (88.23%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (84.61%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t363 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (93.33%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t852 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (87.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t657 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (87.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCC<span class="elsevierStyleItalic">mec</span> type VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">t172 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392764.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Clinical and molecular characteristics of <span class="elsevierStyleItalic">S. aureus</span> strains isolated from infected medical implants.</p>" ] ] 6 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "ODc=Average OD of negative control+3×SD of negative control." "Fichero" => "STRIPIN_si1.jpeg" "Tamanyo" => 4250 "Alto" => 15 "Ancho" => 466 ] ] 7 => array:5 [ "identificador" => "eq0010" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "If ODs≤ODc   then non-adherentIf ODc<ODs≤2×ODc   then weakly adherentIf   2×ODc<ODs≤4×ODc   then moderately adherentIf   4×ODc<ODs<ODc   then strongly adherent" "Fichero" => "STRIPIN_si2.jpeg" "Tamanyo" => 11524 "Alto" => 95 "Ancho" => 392 ] ] 8 => array:5 [ "identificador" => "eq0015" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "ODinhibition(ODi)=OD560   in presence of antibioticsOD560   in absence of antibiotics" "Fichero" => "STRIPIN_si3.jpeg" "Tamanyo" => 4947 "Alto" => 34 "Ancho" => 354 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biofilm in implant infections: its production and regulation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.W. Costerton" 1 => "L. Montanaro" 2 => "C.R. Arciola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Artif Organs" "fecha" => "2005" "volumen" => "28" "paginaInicial" => "1062" "paginaFinal" => "1068" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16353112" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0200" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implant infection and infection resistant materials: a mini review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.R. Arciola" 1 => "F.I. Alvi" 2 => "Y.H. An" 3 => "D. Campoccia" 4 => "L. Montanaro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Artif Organs" "fecha" => "2005" "volumen" => "28" "paginaInicial" => "1119" "paginaFinal" => "1125" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16353118" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0205" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Wisplinghoff" 1 => "T. Bischoff" 2 => "S.M. Tallent" 3 => "H. Seifert" 4 => "R.P. Wenzel" 5 => "M.B. Edmond" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/421946" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2004" "volumen" => "39" "paginaInicial" => "309" "paginaFinal" => "317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15306996" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0210" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microbial composition and antibiotic resistance of biofilms recovered from endotracheal tubes of mechanically ventilated patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Vandecandelaere" 1 => "T. Coenye" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2015" "paginaInicial" => "137" "paginaFinal" => "155" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0215" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Staphylococcus aureus</span> endocarditis: a consequence of medical progress" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "V.G. Fowler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.293.24.3012" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2005" "volumen" => "293" "paginaInicial" => "3012" "paginaFinal" => "3021" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15972563" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0220" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Valvular heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Braunwald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:7 [ "editores" => "E.Braunwald" "paginaInicial" => "1007" "paginaFinal" => "1066" "edicion" => "5th ed." 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Etienne" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Microbes N Infect" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "15" "paginaFinal" => "20" ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0375" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Zinc-dependent mechanical properties of <span class="elsevierStyleItalic">Staphylococcus aureus</span> biofilm-forming surface protein SasG" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Formosa-Dague" 1 => "P. Speziale" 2 => "T.J. Foster" 3 => "J.A. Geoghegan" 4 => "Y.F. Dufrene" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1073/pnas.1519265113" "Revista" => array:6 [ "tituloSerie" => "PNAS" "fecha" => "2016" "volumen" => "113" "paginaInicial" => "410" "paginaFinal" => "415" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26715750" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack277733" "titulo" => "Acknowledgements" "texto" => "<p id="par0165" class="elsevierStylePara elsevierViewall">Authors are highly indebted to Dr. Wilma Ziebuhr, Institute for Molecular Infection Biology, University of Wuerzburg, Germany for providing the control strains for SCC<span class="elsevierStyleItalic">mec</span> types. Authors also thank Dr. Vijay Kumar and Dr. Uma Belavadi of Department of Microbiology, JSS Medical College, Mysuru and Dr. Shilpa of Department of Microbiology, K.R. Hospital, Mysuru for providing device-associated <span class="elsevierStyleItalic">S. aureus</span> strains.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000003500000004/v1_201704140226/S2529993X17300928/v1_201704140226/en/main.assets" "Apartado" => array:4 [ "identificador" => "63564" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000003500000004/v1_201704140226/S2529993X17300928/v1_201704140226/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X17300928?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 15 | 5 | 20 |
| 2024 September | 9 | 10 | 19 |
| 2024 August | 10 | 7 | 17 |
| 2024 July | 14 | 4 | 18 |
| 2024 June | 17 | 4 | 21 |
| 2024 May | 7 | 0 | 7 |
| 2024 April | 27 | 12 | 39 |
| 2024 March | 25 | 6 | 31 |
| 2024 February | 14 | 2 | 16 |
| 2024 January | 23 | 9 | 32 |
| 2023 December | 22 | 3 | 25 |
| 2023 November | 26 | 5 | 31 |
| 2023 October | 28 | 4 | 32 |
| 2023 September | 24 | 7 | 31 |
| 2023 August | 19 | 5 | 24 |
| 2023 July | 7 | 5 | 12 |
| 2023 June | 16 | 3 | 19 |
| 2023 May | 44 | 6 | 50 |
| 2023 April | 24 | 5 | 29 |
| 2023 March | 52 | 4 | 56 |
| 2023 February | 14 | 4 | 18 |
| 2023 January | 56 | 9 | 65 |
| 2022 December | 52 | 9 | 61 |
| 2022 November | 35 | 12 | 47 |
| 2022 October | 14 | 17 | 31 |
| 2022 September | 21 | 6 | 27 |
| 2022 August | 17 | 8 | 25 |
| 2022 July | 21 | 7 | 28 |
| 2022 June | 16 | 6 | 22 |
| 2022 May | 15 | 15 | 30 |
| 2022 April | 19 | 8 | 27 |
| 2022 March | 18 | 12 | 30 |
| 2022 February | 10 | 9 | 19 |
| 2022 January | 14 | 7 | 21 |
| 2021 December | 11 | 9 | 20 |
| 2021 November | 11 | 8 | 19 |
| 2021 October | 6 | 8 | 14 |
| 2021 September | 7 | 7 | 14 |
| 2021 August | 12 | 8 | 20 |
| 2021 July | 8 | 5 | 13 |
| 2021 June | 13 | 10 | 23 |
| 2021 May | 17 | 10 | 27 |
| 2021 April | 34 | 6 | 40 |
| 2021 March | 12 | 3 | 15 |
| 2021 February | 7 | 11 | 18 |
| 2021 January | 9 | 7 | 16 |
| 2020 December | 7 | 5 | 12 |
| 2020 November | 16 | 12 | 28 |
| 2020 October | 6 | 3 | 9 |
| 2020 September | 7 | 9 | 16 |
| 2020 August | 7 | 6 | 13 |
| 2020 July | 8 | 10 | 18 |
| 2020 June | 7 | 4 | 11 |
| 2020 May | 7 | 7 | 14 |
| 2020 April | 6 | 1 | 7 |
| 2020 March | 8 | 4 | 12 |
| 2020 February | 6 | 3 | 9 |
| 2020 January | 7 | 2 | 9 |
| 2019 December | 15 | 7 | 22 |
| 2019 November | 8 | 11 | 19 |
| 2019 October | 10 | 5 | 15 |
| 2019 September | 8 | 3 | 11 |
| 2019 August | 5 | 7 | 12 |
| 2019 July | 6 | 5 | 11 |
| 2019 June | 31 | 16 | 47 |
| 2019 May | 94 | 21 | 115 |
| 2019 April | 40 | 30 | 70 |
| 2019 March | 4 | 6 | 10 |
| 2019 February | 8 | 5 | 13 |
| 2019 January | 10 | 2 | 12 |
| 2018 December | 15 | 2 | 17 |
| 2018 November | 8 | 13 | 21 |
| 2018 October | 6 | 6 | 12 |
| 2018 September | 14 | 2 | 16 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 9 | 1 | 10 |
| 2018 June | 9 | 2 | 11 |
| 2018 May | 6 | 2 | 8 |
| 2018 April | 12 | 1 | 13 |
| 2018 March | 3 | 0 | 3 |
| 2018 February | 3 | 0 | 3 |
| 2018 January | 6 | 0 | 6 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 7 | 0 | 7 |
| 2017 October | 8 | 1 | 9 |
| 2017 September | 2 | 1 | 3 |
| 2017 May | 5 | 0 | 5 |
| 2017 April | 1 | 0 | 1 |
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