Scientific letter
Osteoarticular infections in pediatric patients: The aetiological importance of Kingella kingae
Infecciones osteoarticulares en pediatria: importancia etiológica de Kingella kingae
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"autoresLista" => "Amadeu Gené Giralt, Guillermo Ludwig Sanz-Orrio, Carmen Muñoz-Almagro, Antoni Noguera-Julián" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Amadeu" "apellidos" => "Gené Giralt" "email" => array:1 [ 0 => "agene@hsjdbcn.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Guillermo" "apellidos" => "Ludwig Sanz-Orrio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Carmen" "apellidos" => "Muñoz-Almagro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Antoni" "apellidos" => "Noguera-Julián" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Microbiology, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Infectious Diseases Unit, Department of Pediatrics, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones osteoarticulares en pediatria: importancia etiológica de Kingella kingae" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoarticular infection frequently remains microbiologically unconfirmed in the pediatric age.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Since the early 1990s <span class="elsevierStyleItalic">Kingella kingae</span> has emerged as a major etiological agent of osteomyelitis and septic arthritis in children aged less than 4 years.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Recently, the implementation of molecular detection assays (MDA) has established the real role of this microorganism in osteoarticular infections.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective study in a cohort of pediatric patients (<18 years at inclusion) diagnosed with septic arthritis and osteomyelitis between January 2012 and May 2016 at Hospital Sant Joan de Déu (Barcelona). Samples were obtained through arthrocentesis or arthrotomy in arthritis and bone debridement in osteomielitis. Depending on the volume of the drained material, samples were partly inoculated in situ in aerobic blood culture bottles (SBCB) (BacT/ALERT, BioMérieux; USA) by the orthopedic surgeon. In febrile patients, blood cultures (BC) from peripheral veins were also obtained. Samples were processed by means of routine microbiological procedures (gram staining; blood agar, blood anaerobic agar, chocolate agar and tioglicolate medium cultures), inoculated in BCB, when it was not previously done, and to be tested by specific real-time PCR.</p><p id="par0015" class="elsevierStylePara elsevierViewall">PCR targeting the <span class="elsevierStyleItalic">rtx</span>A toxin gene of <span class="elsevierStyleItalic">K. kingae</span> (accession number <a id="intr0005" class="elsevierStyleInterRef" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=nucleotide&doptcmdl=genbank&term=EF067866">EF067866</a>) slighted adapted from a previously PCR design.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The primers and probe used in our site were KK-forward (5′-GCGCACAAGCAGGTGTACAA-3′), KK-reverse (5′-ACCTGCTGCTACTGTACCTGTTTTAG-3′) and the TaqMan probe (6FAM-5′-CTTTGAACAAAGCTGGACACGCAGC-3′-BBQ). Real-time for LytA gene of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> and CtxrA gene for <span class="elsevierStyleItalic">Neisseria meningitidis</span> were also performed.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">During the study period, samples from 88 patients (42.0% females, median [IQR] age: 2.1 [1.2–6.8] years) were processed. In 51 (58.0%) patients, blood cultures were also performed. Diagnosis included 67 septic arthritis and 21 osteomyelitis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Overall, 49 cases (55.7%) were microbiologically confirmed, including 38 (56.7%) cases of septic arthritis and 11 (52.4%) cases of osteomyelitis. <span class="elsevierStyleItalic">K. kingae</span> (25 cases, 51%) and <span class="elsevierStyleItalic">Staphylococcus aureus</span> (18 cases, 36.7%) were the most frequent pathogens. Hip (13), knee (11), ankle (8), elbow (4), shoulder (2) tibia (5), femur (2) ulna (1), fibula (1), astragalus (1) and sternum (1) were the joins and bones affected.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the distribution of culture and real-time PCR results in patients with microbiologically confirmed osteoarticular infection according to the clinical diagnosis, the age and the species detected.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus agalactiae</span> was isolated in 2 out of the 3 cases of septic arthritis diagnosed in patients younger than 6 months.</p><p id="par0040" class="elsevierStylePara elsevierViewall">All 25 cases (92% with septic arthritis) of osteoarticular infections caused by <span class="elsevierStyleItalic">K. Kingae</span> were observed in patients aged between 6 months and 4 years. Only 10 (40%) strains of <span class="elsevierStyleItalic">K. kingae</span> were identified by one of the culture methods used (10 in SBCB and 3 also in routine cultures), but 100% of them tested positive by real-time PCR. In patients aged over 4 years (54.8% with septic arthritis) <span class="elsevierStyleItalic">S. aureus</span> was the most frequent pathogen and was found in 17 (54.8%) out of 31 cases. Most <span class="elsevierStyleItalic">S. aureus</span> isolates (15 out of 18) grew both in BCB and routine culture, while the other 3 were only isolated in BC.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Etiological diagnosis was exclusively attributable to real-time PCR in 17 out of 49 cases (34.7%).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Overall, patients with arthritis were younger (1.5 vs 6.5 years) and more often diagnosed with <span class="elsevierStyleItalic">K. kingae</span> infections (34.3% vs 9.5%) than those affected with osteomyelitis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This study shows that the bacterial etiology of osteoarticular infections in children is closely related to the age of patient, and clearly outlines three different periods. During the first months of life osteoarticular infection is an infrequent event but usually caused by group B streptococci, as in late-onset neonatal sepsis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleItalic">K. kingae</span> almost exclusively affects infants and toddlers, in fact, in 22 out of 25 (88%) <span class="elsevierStyleItalic">K. kingae</span> cases, patients were aged between six months and two years. Because <span class="elsevierStyleItalic">K. kingae</span> osteoarticular infections usually associate negative gram stain (100% in this study), mild clinical symptoms and mild alteration of plasmatic inflammation markers,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> differential diagnosis with non-infectious causes of arthritis (i.e. transient synovitis of the hip) is difficult.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In these cases, culture in SBCB is important to isolate the microorganism,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> but MDA are critical for proper diagnosis and early treatment. That is why, specific <span class="elsevierStyleItalic">K. kingae</span> MDA should be available as a routine test in hospitals with pediatric patients. MDA also improve the detection of <span class="elsevierStyleItalic">S. pneumoniae</span> and <span class="elsevierStyleItalic">N. meningitidis</span>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients aged >4 years, <span class="elsevierStyleItalic">S. aureus</span> remains the main cause of both arthritis and osteomyelitis,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> in our study 94.4% cases. Due to the efficiency of routine cultures for <span class="elsevierStyleItalic">S. aureus</span>, inoculation of samples in BCB does not improve the isolation rate. Moreover, previous studies have shown that <span class="elsevierStyleItalic">S. aureus</span>-specific PCR assays offer no advantages over classical cultures.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study has not received specific funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => 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:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">RC: Routine culture.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SBCB: Osteoarticular sample in blood-culture bottle.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BC: Blood culture.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">PCR: Molecular methods.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AR: Arthritis.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">OM: Osteomyelitis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients (AR-OM) \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">Bacteriologically documented (AR-OM) \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">RC \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">RC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SBCB \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">RC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SBCB<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>BC \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">RC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SBCB<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>BC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PCR \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"><span class="elsevierStyleItalic">Osteoarticular infections</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 (67–21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (38–11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (23.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (31.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (36.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 (55.7%) \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="elsevierStyleHsp" style=""></span><6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (3–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (66.7%) \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="elsevierStyleHsp" style=""></span>≥6 months <4 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 (47–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (26–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (11.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (24.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (24.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (53.7%) \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="elsevierStyleHsp" style=""></span>≥4 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (17–14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (10–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (45.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (45.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (54.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (58.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" 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"><span class="elsevierStyleItalic">Arthritis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (17.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (27.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (32.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 (56.7%) \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">Osteomyelitis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \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">9 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (47.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (47.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (52.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" 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"><span class="elsevierStyleItalic">Kingella kingae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (100%) \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">Staphylococcus aureus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (83.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (83.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \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">Streptococcus pneumoniae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (100%) \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">Streptococcus agalactiae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \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">Neisseria meningitidis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">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="left" valign="top">1 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1972407.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of culture and molecular methods results in patients with microbiologically osteoarticular infection according to disease type (septic arthritis or osteomyelitis), age and the species detected.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O.A. 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| 2024 June | 6 | 2 | 8 |
| 2024 May | 17 | 0 | 17 |
| 2024 April | 8 | 4 | 12 |
| 2024 March | 10 | 0 | 10 |
| 2024 February | 16 | 8 | 24 |
| 2024 January | 8 | 3 | 11 |
| 2023 December | 7 | 5 | 12 |
| 2023 November | 11 | 5 | 16 |
| 2023 October | 16 | 5 | 21 |
| 2023 September | 17 | 0 | 17 |
| 2023 August | 6 | 6 | 12 |
| 2023 July | 10 | 6 | 16 |
| 2023 June | 12 | 2 | 14 |
| 2023 May | 22 | 2 | 24 |
| 2023 April | 36 | 2 | 38 |
| 2023 March | 20 | 3 | 23 |
| 2023 February | 18 | 0 | 18 |
| 2023 January | 48 | 6 | 54 |
| 2022 December | 8 | 4 | 12 |
| 2022 November | 12 | 3 | 15 |
| 2022 October | 11 | 10 | 21 |
| 2022 September | 11 | 9 | 20 |
| 2022 August | 9 | 8 | 17 |
| 2022 July | 8 | 6 | 14 |
| 2022 June | 5 | 5 | 10 |
| 2022 May | 10 | 4 | 14 |
| 2022 April | 10 | 7 | 17 |
| 2022 March | 37 | 7 | 44 |
| 2022 February | 15 | 5 | 20 |
| 2022 January | 23 | 4 | 27 |
| 2021 December | 14 | 12 | 26 |
| 2021 November | 8 | 7 | 15 |
| 2021 October | 28 | 10 | 38 |
| 2021 September | 12 | 8 | 20 |
| 2021 August | 24 | 10 | 34 |
| 2021 July | 13 | 9 | 22 |
| 2021 June | 4 | 7 | 11 |
| 2021 May | 14 | 7 | 21 |
| 2021 April | 19 | 3 | 22 |
| 2021 March | 9 | 9 | 18 |
| 2021 February | 10 | 13 | 23 |
| 2021 January | 11 | 5 | 16 |
| 2020 December | 12 | 6 | 18 |
| 2020 November | 9 | 10 | 19 |
| 2020 October | 8 | 3 | 11 |
| 2020 September | 17 | 8 | 25 |
| 2020 August | 4 | 8 | 12 |
| 2020 July | 10 | 12 | 22 |
| 2020 June | 12 | 11 | 23 |
| 2020 May | 9 | 7 | 16 |
| 2020 April | 10 | 1 | 11 |
| 2020 March | 9 | 2 | 11 |
| 2020 February | 7 | 4 | 11 |
| 2020 January | 8 | 2 | 10 |
| 2019 December | 13 | 5 | 18 |
| 2019 November | 3 | 3 | 6 |
| 2019 October | 6 | 2 | 8 |
| 2019 September | 4 | 4 | 8 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
Show all
