Assessment of a semi-automated enrichment system (Uroquattro HB&L) for detection of faecal carriers of ESBL-/AmpC-producing Enterobacterales | Enfermedades Infecciosas y Microbiología Clínica (English Edition)

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[ 0 => array:2 [ "autoresLista" => "Joffrey Eduardo Luján-Valencia, Luis Eduardo López-Cortes, Román Calvo-Jambrina, José Miguel Barquero-Aroca, Juan Gálvez-Acebal" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Joffrey Eduardo" "apellidos" => "Luján-Valencia" ] 1 => array:2 [ "nombre" => "Luis Eduardo" "apellidos" => "López-Cortes" ] 2 => array:2 [ "nombre" => "Román" "apellidos" => "Calvo-Jambrina" ] 3 => array:2 [ "nombre" => "José Miguel" "apellidos" => "Barquero-Aroca" ] 4 => array:2 [ "nombre" => "Juan" "apellidos" => "Gálvez-Acebal" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X20301593?idApp=UINPBA00004N" "url" => "/2529993X/0000003800000008/v1_202010030701/S2529993X20301593/v1_202010030701/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Brief report" "titulo" => "Assessment of a semi-automated enrichment system (Uroquattro HB&L) for detection of faecal carriers of ESBL-/AmpC-producing Enterobacterales" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "367" "paginaFinal" => "370" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Patricia Pérez-Palacios, Lorena López-Cerero, Carmen Lupión, Alvaro Pascual" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Patricia" "apellidos" => "Pérez-Palacios" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Lorena" "apellidos" => "López-Cerero" "email" => array:1 [ 0 => "llopez@us.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Carmen" "apellidos" => "Lupión" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Alvaro" "apellidos" => "Pascual" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Microbiology, School of Medicine of University of Seville, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de un sistema de enriquecimiento semiautomático (Uroquattro HB&L™) para la detección de portadores fecales de Enterobacterales productoras de beta-lactamasas de espectro extendido (BLEE)/AmpC" ] ] "textoCompleto" => "IntroductionEnterobacterales resistant to third-generation cephalosporins due to the acquisition of extended-spectrum beta-lactamases and plasmid-mediated cephalosporinases (ESBLs/pAmpC) currently constitute one of the most pressing medical problems worldwide. The growing dissemination of carbapenemase producers, many of them also resistant to third-generation cephalosporins, and the co-resistance pattern of these microorganisms represents an added problem.<a class="elsevierStyleCrossRef" href="#bib0080">1</a> Early detection of patients carrying ESBL-/pAmpC-/carbapenemase-producing Enterobacterales (3GCRE) using surveillance cultures on admission and isolation of colonized patients is a major strategy designed to prevent the spread of resistance genes.<a class="elsevierStyleCrossRef" href="#bib0085">2</a>Recent advances in the detection of 3GCRE are based on molecular techniques or chromogenic selective media.<a class="elsevierStyleCrossRef" href="#bib0090">3</a> Molecular techniques continue to be the gold standard due to their high, almost 100% sensitivity and specificity. All of them are based on amplification of the main genes involved in these enzymes in 1–3h.<a class="elsevierStyleCrossRef" href="#bib0095">4</a> Nevertheless, the cost of molecular methods and the limited targets available restrict their systematic implementation. Chromogenic selective media are the cheapest and easiest technique for detection of 3GCRE and more cost effective<a class="elsevierStyleCrossRef" href="#bib0100">5</a> despite their lower sensitivity (around 80%) and the longer time taken to obtain results (between 24 and 48h).<a class="elsevierStyleCrossRef" href="#bib0100">5</a>Another strategy that improves detection of colonized patients is to add a pre-enrichment step.<a class="elsevierStyleCrossRef" href="#bib0105">6</a> The main inconvenience of enrichment is the delay associated with obtaining results.<a class="elsevierStyleCrossRef" href="#bib0110">7</a> The Uroquattro HB&L (Alifax®) is a new system based on a selective pre-enrichment medium and continuous measurement of growth curves using light scattering technology, designed to increase the detection of third-generation cephalosporin-resistant Enterobacterales. The aim of this study was to compare a selective medium routinely used in our laboratory with the semi-automated Uroquattro HB&L system (Alifax®).Material and methodsPatients and microbiological analysisThe study was performed at the University Hospital Virgen Macarena (a 900-bed tertiary hospital) in Seville, Spain. From June to October 2017, consecutive double rectal swabs were collected (Copan®, Italy) from 201 inpatients included in the local surveillance programme (upon ICU admission, previous colonization status, transfers from other centres and roommates of positive cases). One swab was plated on the routinely used medium (MacConkey agar supplemented with cefotaxime 4μg/ml) and incubated at 35°C for 18h. Results from routine medium were reported in 18–24h (for negative results when no growth of Enterobacterales was observed) and in 48h (for negative results with growth of non 3CGRE or positive results). The second swab was inoculated into the Uroquattro HB&L system (UHBL). UHBL is a semi-automatic analyser that uses a light scattering technology to test bacteria susceptibility on rectal swabs. UHBL measures the growth of bacteria in specific selective enrichment broths providing real time growth curves and bacterial counts (CFU/ml) every hour with a specific interpretation algorithm. Measurements of the growth curve were taken at 6.5h (according to the manufacturer's instructions) and at 10h (to assess whether longer incubation might increase detection). Positive samples were subcultured in MacConkey agar containing cefotaxime (4mg/l). All isolates detected by both methods were identified by MALDI-TOF (Bruker). Screening for ESBL or pAmpC production was performed on Mueller-Hinton agar plates with or without cloxacillin (200mg/l), with double discs according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines.The presence of bla genes (ESBL: blaSHV, blaCTX-M-1, blaCTX-M-9; pAmpC: blaMOX, blaCIT, blaDHA, blaACC, blaEBC, blaCMY and blaFOX; carbapenemase: blaKPC, blaNDM, blaVIM, blaIMP and blaOXA-48) was studied by PCR using specific group primers<a class="elsevierStyleCrossRef" href="#bib0095">4</a> and further sequencing of amplicons. The reference value was the combination of obtained from both methods.Statistical analysisTo assess of concordant and discordant results, percent agreement and the exact McNemar test were calculated (SPSS Statistics, version 23.0) for 3GCRE positives and negatives rectal swab of UHBL system at 6.5 and at 10h and the routine medium.ResultsA total of 35 samples (17.4%) were positive for 3GCRE. E. coli (n=22) was the most prevalent microorganism (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Among ESBL enzymes, the most frequent was CTX-M-15 (n=14, 37.8%); pAmpC (CMY-2) and carbapenemases (KPC-2 and VIM-1) were also found (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Measurements of the UHBL system at 6.5h and 10h were compared to direct culture on solid medium for all 3GCRE positive and negative cultures (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Thirty-five rectal swabs were positive for 3GCRE for both UHBL system and routine medium, whereas 4 and 7 rectal swabs were positive only with UHBL system at 6.5h and 10h, respectively (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Measurements at 10h incremented a 5.7% (95% confidence interval [CI], 1.5–1.8%) (2/35) the positive 3GCRE detection in comparison with the routine culture medium. The increments of false positive results were 1.2% (95% confidence interval [CI], 0.3–0.4%) (2/166), and 7.2% (95% confidence interval [CI], 4.1–12.2%) (12/166), at 6.5h and 10h, respectively.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionActive screening cultures to prevent nosocomial infections and outbreaks are performed in many hospitals,<a class="elsevierStyleCrossRef" href="#bib0115">8</a> although an optimal screening protocol has not yet been established.<a class="elsevierStyleCrossRef" href="#bib0115">8</a> The present study evaluates for the first time a semi-automated screening system, the Uroquattro HB&L, which provides early and higher detection of faecal carriers of ESBL-/pAmpC-/carbapenemase-producing Enterobacterales.There are two aspects of carrier detection surveillance that are fundamental: firstly, the accuracy of the method and secondly, the time to detection.<a class="elsevierStyleCrossRef" href="#bib0120">9</a> The use of a pre-enrichment step increases the detection efficiency in comparison to the usual strategy of inoculating samples directly onto selective solid media, at the expenses of longer detection time and higher false positive rates. The results obtained in a previous study comparing solid and pre-enrichment cultures<a class="elsevierStyleCrossRef" href="#bib0125">10</a> found an agreement in negative samples of 96.8%, consistent with our results. Previous studies yielded higher increases of detection with the enrichment (25.9%<a class="elsevierStyleCrossRef" href="#bib0125">10</a> and 20%<a class="elsevierStyleCrossRef" href="#bib0130">11</a> compared with 5.7% in our study) and lower increases of false positive rates (2.1%<a class="elsevierStyleCrossRef" href="#bib0125">10</a> and 0.5%<a class="elsevierStyleCrossRef" href="#bib0130">11</a> compared with our study), taken into account lower prevalence of ESBL producer positive patients (4.8%<a class="elsevierStyleCrossRef" href="#bib0125">10</a> and 9%,<a class="elsevierStyleCrossRef" href="#bib0130">11</a> compared to 18.4% in our study). The variation between the yield and the false positive rate with pre-enrichment, may increase when the prevalence of ESBL/AmpC carriers rise. Rectal swabs negative by direct culture and positive by enrichment may be due to low bacterial loads, which may have less epidemiological relevance, although these bacterial loads may variate depending on time of hospitalization and antibiotic exposure. Selection of previous detected ESBL producers have been seen in patients with negative samples without enrichment upon admission of the ICU.<a class="elsevierStyleCrossRef" href="#bib0135">12</a> Follow-up studies are necessary to establish the risk of transmission according to faecal load.Uroquattro HB&L system reduces the time of detection to 6.5h, according to the manufacturer, although an increment in detection was obtained at 10h according to our results. Nevertheless, both 6.5h and 10h enable the characterization of 3CGRE to begin on the same day that the sample is received and, a more important issue, shortening the time for negative results. Earlier detection could have an impact on costs. Sypsa et al.,<a class="elsevierStyleCrossRef" href="#bib0140">13</a> using a mathematical model, concluded that a delay in detection, even by one day, increased the costs associated with outbreaks. On the other hand, an earlier negative result may have an impact by reducing the adverse effects of isolation, such as supportive care failures due less time spent by health workers or patient mental problems.<a class="elsevierStyleCrossRef" href="#bib0145">14</a> Molecular methods could reduce even more the result time, but a higher cost.<a class="elsevierStyleCrossRef" href="#bib0150">15</a>This study had limitations. In our study we used the Copan Transystem™ swabs with Amies solid medium, while the manufacturer of the semi-automated system recommends the use of nylon-flocked swabs with Amies liquid (ESwab). However, not all hospitals have introduced the use of the ES-swab®, and our results could be valid in these situations. Another limitation is that we did not inoculated the rectal swabs on blood agar as a control of enteric microbiota. In addition, this system does not detect OXA-48 producers not co-producing ESBL/AmpC, but the prevalence of infections due to these microorganisms is very low in our area.In conclusion, the use of a preenrichment semi-automatic system Uroquattro HB&L in rectal swabs improved the detection of ESBL/pAmpC faecal carriers with an incubation time of 10h, shortening the reporting time of negative results.FundingThis work was partially supported by Plan Nacional de I+D+i 2013–2016 and Instituto de Salud Carlos III, subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Economía, Industria y Competitividad, Spanish Network for Research in Infectious Diseases (RD16/0016/0001) co-financed by European Development Regional Fund “A way to achieve Europe”, Operative program Intelligent Growth 2014–2020.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1394164" "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" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1277765" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1394165" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1277766" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients and microbiological analysis" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-09" "fechaAceptado" => "2019-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1277765" "palabras" => array:5 [ 0 => "ESBL" 1 => "pAmpC" 2 => "Third generation cephalosporins resistance" 3 => "Enrichment" 4 => "Uro-Quick system" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1277766" "palabras" => array:5 [ 0 => "ESBL" 1 => "pAmpC" 2 => "Resistencia a las cefalosporinas de tercera generación" 3 => "Enriquecimiento" 4 => "Sistema Uro-Quick" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionEarly detection of patients carrying multiresistant bacteria is an effective implement in surveillance programs. Our objective was to compare the semi-automatic Uroquattro HB&L “ESBL/AmpC Screening” (Alifax®) system with the routine culture on selective media to detect ESBL/pAmpC-producing microorganisms (3CGRE). MethodsA total of 201 rectal swabs samples were processed by inoculating them into the Uroquattro HB&L system, performing growth curve measurements at 6.5 and 10h, and into direct culture medium. ResultsThirty-five samples yielded 3CGRE. Measurements at 10h incremented the positive 3GCRE detection 5.7% in comparison with routine culture medium. In negative rectal swabs, the overall percent agreement at 6.5h and 10h versus routine culture medium was 93% and 90%, respectively. ConclusionsThe Uroquattro HB&L system increased the detection of ESBL/pAmpC-producing bacteria compared to direct plating with an incubation time of 10h and shortens the time to report a negative sample." "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" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa detección temprana de pacientes portadores de bacterias multirresistentes es una medida eficaz de los programas de vigilancia. Nuestro objetivo fue comparar el sistema semiautomático Uroquattro HB&L™ «ESBL/AmpCscreening» (Alifax®) frente al cultivo habitual en medios selectivos para detectar microorganismos productores de beta-lactamasas de espectro extendido (BLEE)/AmpC (3CGRE). MétodosSe procesaron 201 frotis rectales mediante inoculación en el sistema Uroquattro HB&L™, se midió el crecimiento a las 6,5 y 10h, y en el medio de cultivo directo. ResultadosTreinta y cinco muestras fueron positivas para 3CGRE. La lectura a las 10h incrementó la detección un 5,7% en comparación con el medio habitual. En muestras rectales negativas, la concordancia de la lectura global a las 6,5 y 10h con el medio de cultivo habitual fue del 93 y 90%, respectivamente. ConclusionesEl sistema Uroquattro HB&L™ incrementó la detección de bacterias productoras de BLEE/pAmpC en comparación con el cultivo directo con un tiempo de incubación de 10h y acorta los tiempos de detección de muestras negativas." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:2 [ 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:3 [ "leyenda" => "1 rectal swab=E. coli (CTX-M-15+CMY-2).1 rectal swab=E. coli (CTX-M-14)+K. oxytoca (CTX-M-14).1 rectal swab=E. gergoviae (KPC-2+SHV-12).1 rectal swab=E. coli (CTX-M-15)+K. pneumoniae (CTX-M-14).2 rectal swabs=E. coli (CTX-M-14)+K. pneumoniae (CTX-M-15)." "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-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Type of determinant \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="6" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. of isolates (%)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Escherichia coli</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Klebsiella spp.<a class="elsevierStyleCrossRef" href="#tblfn0045">a</a></th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Enterobacter spp.<a class="elsevierStyleCrossRef" href="#tblfn0050">b</a></th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n=22)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n=13)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n=4)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESBL</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTX-M-15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(15.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(15.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTX-M-14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(25.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTX-M-9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTX-M-32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTX-M-27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SHV-12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AmpC</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CMY-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Carbapenemase</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">KPC-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VIM-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total no. genes: 42<a class="elsevierStyleCrossRef" href="#tblfn0055">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(59.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(28.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(12%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2392688.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "a" "nota" => "K. pneumoniae (n=11), K. oxytoca (n=2)." ] 1 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "b" "nota" => "E. cloacae (n=2), E. gergoviae (n=1), E. hormachei (n=1)." ] 2 => array:3 [ "identificador" => "tblfn0055" "etiqueta" => "c" "nota" => "1 rectal swab=E. coli (CTX-M-15+CTX-M-14)+K. pneumoniae (CTX-M-14)." ] ] ] "descripcion" => array:1 [ "en" => "Distribution of Enterobacterales and enzymes among the 35 positive rectal swabs." ] ] 1 => 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:3 [ "leyenda" => "Positive results were considered the detection of ESBL/pAmpC producers. Negative results were considered lack of growth or growth of third-generation cephalosporins resistant Gram-negative but not ESBL/pAmpC producers." "tablatextoimagen" => array:2 [ 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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">UHBL results</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. of 3CGRE positive samples</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. of 3CGRE negative samples</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">At 6.5h</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results with routine culture medium \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0025">b</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0025">b</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">155 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2392690.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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">At 10h</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results with routine culture medium \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0030">c</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0030">c</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0035">d</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0035">d</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">147 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2392689.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "Overall percent agreement, 45.7% (95% confidence interval [CI], 30.4–61.8%); exact McNemar test, p=0.74." ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "b" "nota" => "Overall percent agreement, 93% (95% confidence interval [CI], 89.2–96.7%); exact McNemar test, p=0.01." ] 2 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "c" "nota" => "Overall percent agreement, 65% (95% confidence interval [CI], 49.1–79.1%); exact McNemar test, p=0.77." ] 3 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "d" "nota" => "Overall percent agreement, 90% (95% confidence interval [CI], 84.2–93.9%); exact McNemar test, p=0.004." ] 4 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "*" "nota" => "UHBL: Uroquattro HB&L system." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the UHBL<a class="elsevierStyleCrossRef" href="#tblfn0040">*</a> system at 6.5h and 10h with the routine culture medium." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "AmpC disk test for detection of plasmid-mediated AmpC β-lactamases in Enterobacteriaceae lacking chromosomal AmpC β-lactamases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. Black" 1 => "E.S. Moland" 2 => "K.S. Thomson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.43.7.3110-3113.2005" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2005" "volumen" => "43" "paginaInicial" => "3110" "paginaFinal" => "3113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16000421" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical impact and relevance of antibiotic resistance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.L. French" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.addr.2005.04.005" "Revista" => array:6 [ "tituloSerie" => "Adv Drug Deliv Rev" "fecha" => "2005" "volumen" => "57" "paginaInicial" => "1514" "paginaFinal" => "1527" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15978698" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current trends in culture-based and molecular detection of extended-spectrum-β-lactamase-harboring and carbapenem-resistant Enterobacteriaceae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Gazin" 1 => "F. Paasch" 2 => "H. Goossens" 3 => "S. Malhotra-Kumar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.06852-11" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2012" "volumen" => "50" "paginaInicial" => "1140" "paginaFinal" => "1146" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22259207" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0095" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of a set of multiplex PCR assays for the detection of genes encoding important β-lactamases in Enterobacteriaceae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Dallenne" 1 => "A. Da Costa" 2 => "D. Decré" 3 => "C. Favier" 4 => "G. 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Brief report

Assessment of a semi-automated enrichment system (Uroquattro HB&L) for detection of faecal carriers of ESBL-/AmpC-producing Enterobacterales

Evaluación de un sistema de enriquecimiento semiautomático (Uroquattro HB&L™) para la detección de portadores fecales de Enterobacterales productoras de beta-lactamasas de espectro extendido (BLEE)/AmpC

Patricia Pérez-Palaciosa, Lorena López-Cereroa,

Corresponding author

llopez@us.es

Corresponding author.

, Carmen Lupióna, Alvaro Pascuala,b

a Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain

b Department of Microbiology, School of Medicine of University of Seville, Spain

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        "titulo" => "Evaluaci&#243;n de un sistema de enriquecimiento semiautom&#225;tico &#40;Uroquattro HB&#38;L&#8482;&#41; para la detecci&#243;n de portadores fecales de <span class="elsevierStyleItalic">Enterobacterales</span> productoras de beta-lactamasas de espectro extendido &#40;BLEE&#41;&#47;AmpC"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Enterobacterales resistant to third-generation cephalosporins due to the acquisition of extended-spectrum beta-lactamases and plasmid-mediated cephalosporinases &#40;ESBLs&#47;pAmpC&#41; currently constitute one of the most pressing medical problems worldwide&#46; The growing dissemination of carbapenemase producers&#44; many of them also resistant to third-generation cephalosporins&#44; and the co-resistance pattern of these microorganisms represents an added problem&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Early detection of patients carrying ESBL-&#47;pAmpC-&#47;carbapenemase-producing Enterobacterales &#40;3GCRE&#41; using surveillance cultures on admission and isolation of colonized patients is a major strategy designed to prevent the spread of resistance genes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent advances in the detection of 3GCRE are based on molecular techniques or chromogenic selective media&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Molecular techniques continue to be the gold standard due to their high&#44; almost 100&#37; sensitivity and specificity&#46; All of them are based on amplification of the main genes involved in these enzymes in 1&#8211;3<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; the cost of molecular methods and the limited targets available restrict their systematic implementation&#46; Chromogenic selective media are the cheapest and easiest technique for detection of 3GCRE and more cost effective<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> despite their lower sensitivity &#40;around 80&#37;&#41; and the longer time taken to obtain results &#40;between 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Another strategy that improves detection of colonized patients is to add a pre-enrichment step&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> The main inconvenience of enrichment is the delay associated with obtaining results&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> The Uroquattro HB&#38;L &#40;Alifax&#174;&#41; is a new system based on a selective pre-enrichment medium and continuous measurement of growth curves using light scattering technology&#44; designed to increase the detection of third-generation cephalosporin-resistant Enterobacterales&#46; The aim of this study was to compare a selective medium routinely used in our laboratory with the semi-automated Uroquattro HB&#38;L system &#40;Alifax&#174;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and microbiological analysis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study was performed at the University Hospital Virgen Macarena &#40;a 900-bed tertiary hospital&#41; in Seville&#44; Spain&#46; From June to October 2017&#44; consecutive double rectal swabs were collected &#40;Copan&#174;&#44; Italy&#41; from 201 inpatients included in the local surveillance programme &#40;upon ICU admission&#44; previous colonization status&#44; transfers from other centres and roommates of positive cases&#41;&#46; One swab was plated on the routinely used medium &#40;MacConkey agar supplemented with cefotaxime 4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml&#41; and incubated at 35<span class="elsevierStyleHsp" style=""></span>&#176;C for 18<span class="elsevierStyleHsp" style=""></span>h&#46; Results from routine medium were reported in 18&#8211;24<span class="elsevierStyleHsp" style=""></span>h &#40;for negative results when no growth of Enterobacterales was observed&#41; and in 48<span class="elsevierStyleHsp" style=""></span>h &#40;for negative results with growth of non 3CGRE or positive results&#41;&#46; The second swab was inoculated into the Uroquattro HB&#38;L system &#40;UHBL&#41;&#46; UHBL is a semi-automatic analyser that uses a light scattering technology to test bacteria susceptibility on rectal swabs&#46; UHBL measures the growth of bacteria in specific selective enrichment broths providing real time growth curves and bacterial counts &#40;CFU&#47;ml&#41; every hour with a specific interpretation algorithm&#46; Measurements of the growth curve were taken at 6&#46;5<span class="elsevierStyleHsp" style=""></span>h &#40;according to the manufacturer&#39;s instructions&#41; and at 10<span class="elsevierStyleHsp" style=""></span>h &#40;to assess whether longer incubation might increase detection&#41;&#46; Positive samples were subcultured in MacConkey agar containing cefotaxime &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41;&#46; All isolates detected by both methods were identified by MALDI-TOF &#40;Bruker&#41;&#46; Screening for ESBL or pAmpC production was performed on Mueller-Hinton agar plates with or without cloxacillin &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41;&#44; with double discs according to the European Committee on Antimicrobial Susceptibility Testing &#40;EUCAST&#41; guidelines&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The presence of <span class="elsevierStyleItalic">bla</span> genes &#40;ESBL&#58; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">SHV</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M-1</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M-9</span>&#59; pAmpC&#58; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">MOX</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CIT</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">DHA</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">ACC</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">EBC</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CMY</span> and <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">FOX</span>&#59; carbapenemase&#58; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">KPC</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">NDM</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">VIM</span>&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">IMP</span> and <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">OXA-48</span>&#41; was studied by PCR using specific group primers<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and further sequencing of amplicons&#46; The reference value was the combination of obtained from both methods&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">To assess of concordant and discordant results&#44; percent agreement and the exact McNemar test were calculated &#40;SPSS Statistics&#44; version 23&#46;0&#41; for 3GCRE positives and negatives rectal swab of UHBL system at 6&#46;5 and at 10<span class="elsevierStyleHsp" style=""></span>h and the routine medium&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 35 samples &#40;17&#46;4&#37;&#41; were positive for 3GCRE&#46; <span class="elsevierStyleItalic">E&#46; coli</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41; was the most prevalent microorganism &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Among ESBL enzymes&#44; the most frequent was CTX-M-15 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44; 37&#46;8&#37;&#41;&#59; pAmpC &#40;CMY-2&#41; and carbapenemases &#40;KPC-2 and VIM-1&#41; were also found &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Measurements of the UHBL system at 6&#46;5<span class="elsevierStyleHsp" style=""></span>h and 10<span class="elsevierStyleHsp" style=""></span>h were compared to direct culture on solid medium for all 3GCRE positive and negative cultures &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Thirty-five rectal swabs were positive for 3GCRE for both UHBL system and routine medium&#44; whereas 4 and 7 rectal swabs were positive only with UHBL system at 6&#46;5<span class="elsevierStyleHsp" style=""></span>h and 10<span class="elsevierStyleHsp" style=""></span>h&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Measurements at 10<span class="elsevierStyleHsp" style=""></span>h incremented a 5&#46;7&#37; &#40;95&#37; confidence interval &#91;CI&#93;&#44; 1&#46;5&#8211;1&#46;8&#37;&#41; &#40;2&#47;35&#41; the positive 3GCRE detection in comparison with the routine culture medium&#46; The increments of false positive results were 1&#46;2&#37; &#40;95&#37; confidence interval &#91;CI&#93;&#44; 0&#46;3&#8211;0&#46;4&#37;&#41; &#40;2&#47;166&#41;&#44; and 7&#46;2&#37; &#40;95&#37; confidence interval &#91;CI&#93;&#44; 4&#46;1&#8211;12&#46;2&#37;&#41; &#40;12&#47;166&#41;&#44; at 6&#46;5<span class="elsevierStyleHsp" style=""></span>h and 10<span class="elsevierStyleHsp" style=""></span>h&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Active screening cultures to prevent nosocomial infections and outbreaks are performed in many hospitals&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> although an optimal screening protocol has not yet been established&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The present study evaluates for the first time a semi-automated screening system&#44; the Uroquattro HB&#38;L&#44; which provides early and higher detection of faecal carriers of ESBL-&#47;pAmpC-&#47;carbapenemase-producing Enterobacterales&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There are two aspects of carrier detection surveillance that are fundamental&#58; firstly&#44; the accuracy of the method and secondly&#44; the time to detection&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> The use of a pre-enrichment step increases the detection efficiency in comparison to the usual strategy of inoculating samples directly onto selective solid media&#44; at the expenses of longer detection time and higher false positive rates&#46; The results obtained in a previous study comparing solid and pre-enrichment cultures<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> found an agreement in negative samples of 96&#46;8&#37;&#44; consistent with our results&#46; Previous studies yielded higher increases of detection with the enrichment &#40;25&#46;9&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> and 20&#37;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> compared with 5&#46;7&#37; in our study&#41; and lower increases of false positive rates &#40;2&#46;1&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> and 0&#46;5&#37;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> compared with our study&#41;&#44; taken into account lower prevalence of ESBL producer positive patients &#40;4&#46;8&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> and 9&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> compared to 18&#46;4&#37; in our study&#41;&#46; The variation between the yield and the false positive rate with pre-enrichment&#44; may increase when the prevalence of ESBL&#47;AmpC carriers rise&#46; Rectal swabs negative by direct culture and positive by enrichment may be due to low bacterial loads&#44; which may have less epidemiological relevance&#44; although these bacterial loads may variate depending on time of hospitalization and antibiotic exposure&#46; Selection of previous detected ESBL producers have been seen in patients with negative samples without enrichment upon admission of the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> Follow-up studies are necessary to establish the risk of transmission according to faecal load&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Uroquattro HB&#38;L system reduces the time of detection to 6&#46;5<span class="elsevierStyleHsp" style=""></span>h&#44; according to the manufacturer&#44; although an increment in detection was obtained at 10<span class="elsevierStyleHsp" style=""></span>h according to our results&#46; Nevertheless&#44; both 6&#46;5<span class="elsevierStyleHsp" style=""></span>h and 10<span class="elsevierStyleHsp" style=""></span>h enable the characterization of 3CGRE to begin on the same day that the sample is received and&#44; a more important issue&#44; shortening the time for negative results&#46; Earlier detection could have an impact on costs&#46; Sypsa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> using a mathematical model&#44; concluded that a delay in detection&#44; even by one day&#44; increased the costs associated with outbreaks&#46; On the other hand&#44; an earlier negative result may have an impact by reducing the adverse effects of isolation&#44; such as supportive care failures due less time spent by health workers or patient mental problems&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Molecular methods could reduce even more the result time&#44; but a higher cost&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This study had limitations&#46; In our study we used the Copan Transystem&#8482; swabs with Amies solid medium&#44; while the manufacturer of the semi-automated system recommends the use of nylon-flocked swabs with Amies liquid &#40;ESwab&#41;&#46; However&#44; not all hospitals have introduced the use of the ES-swab&#174;&#44; and our results could be valid in these situations&#46; Another limitation is that we did not inoculated the rectal swabs on blood agar as a control of enteric microbiota&#46; In addition&#44; this system does not detect OXA-48 producers not co-producing ESBL&#47;AmpC&#44; but the prevalence of infections due to these microorganisms is very low in our area&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; the use of a preenrichment semi-automatic system Uroquattro HB&#38;L in rectal swabs improved the detection of ESBL&#47;pAmpC faecal carriers with an incubation time of 10<span class="elsevierStyleHsp" style=""></span>h&#44; shortening the reporting time of negative results&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This work was partially supported by <span class="elsevierStyleGrantSponsor" id="gs1">Plan Nacional de I&#43;D&#43;i 2013&#8211;2016</span> and <span class="elsevierStyleGrantSponsor" id="gs2">Instituto de Salud Carlos III&#44; subdirecci&#243;n General de Redes y Centros de Investigaci&#243;n Cooperativa&#44; Ministerio de Econom&#237;a&#44; Industria y Competitividad&#44; Spanish Network for Research in Infectious Diseases</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">RD16&#47;0016&#47;0001</span>&#41; co-financed by <span class="elsevierStyleGrantSponsor" id="gs3">European Development Regional Fund</span> &#8220;A way to achieve Europe&#8221;&#44; Operative program Intelligent Growth 2014&#8211;2020&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Early detection of patients carrying multiresistant bacteria is an effective implement in surveillance programs&#46; Our objective was to compare the semi-automatic Uroquattro HB&#38;L &#8220;ESBL&#47;AmpC Screening&#8221; &#40;Alifax&#174;&#41; system with the routine culture on selective media to detect ESBL&#47;pAmpC-producing microorganisms &#40;3CGRE&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 201 rectal swabs samples were processed by inoculating them into the Uroquattro HB&#38;L system&#44; performing growth curve measurements at 6&#46;5 and 10<span class="elsevierStyleHsp" style=""></span>h&#44; and into direct culture medium&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-five samples yielded 3CGRE&#46; Measurements at 10<span class="elsevierStyleHsp" style=""></span>h incremented the positive 3GCRE detection 5&#46;7&#37; in comparison with routine culture medium&#46; In negative rectal swabs&#44; the overall percent agreement at 6&#46;5<span class="elsevierStyleHsp" style=""></span>h and 10<span class="elsevierStyleHsp" style=""></span>h <span class="elsevierStyleItalic">versus</span> routine culture medium was 93&#37; and 90&#37;&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The Uroquattro HB&#38;L system increased the detection of ESBL&#47;pAmpC-producing bacteria compared to direct plating with an incubation time of 10<span class="elsevierStyleHsp" style=""></span>h and shortens the time to report a negative sample&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La detecci&#243;n temprana de pacientes portadores de bacterias multirresistentes es una medida eficaz de los programas de vigilancia&#46; Nuestro objetivo fue comparar el sistema semiautom&#225;tico Uroquattro HB&#38;L&#8482; &#171;ESBL&#47;<span class="elsevierStyleItalic">AmpC</span><span class="elsevierStyleItalic">screening</span>&#187; &#40;Alifax&#174;&#41; frente al cultivo habitual en medios selectivos para detectar microorganismos productores de beta-lactamasas de espectro extendido &#40;BLEE&#41;&#47;AmpC &#40;3CGRE&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se procesaron 201 frotis rectales mediante inoculaci&#243;n en el sistema Uroquattro HB&#38;L&#8482;&#44; se midi&#243; el crecimiento a las 6&#44;5 y 10<span class="elsevierStyleHsp" style=""></span>h&#44; y en el medio de cultivo directo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Treinta y cinco muestras fueron positivas para 3CGRE&#46; La lectura a las 10<span class="elsevierStyleHsp" style=""></span>h increment&#243; la detecci&#243;n un 5&#44;7&#37; en comparaci&#243;n con el medio habitual&#46; En muestras rectales negativas&#44; la concordancia de la lectura global a las 6&#44;5 y 10<span class="elsevierStyleHsp" style=""></span>h con el medio de cultivo habitual fue del 93 y 90&#37;&#44; respectivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El sistema Uroquattro HB&#38;L&#8482; increment&#243; la detecci&#243;n de bacterias productoras de BLEE&#47;pAmpC en comparaci&#243;n con el cultivo directo con un tiempo de incubaci&#243;n de 10<span class="elsevierStyleHsp" style=""></span>h y acorta los tiempos de detecci&#243;n de muestras negativas&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">AmpC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CMY-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Carbapenemase</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>KPC-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VIM-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Total no&#46; genes&#58;</span> 42<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;59&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;28&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">K&#46; pneumoniae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#44; <span class="elsevierStyleItalic">K&#46; oxytoca</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0050"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">E&#46; cloacae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; <span class="elsevierStyleItalic">E&#46; gergoviae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; <span class="elsevierStyleItalic">E&#46; hormachei</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p>"
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            2 => array:3 [
              "identificador" => "tblfn0055"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">1 rectal swab<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">E&#46; coli</span> &#40;CTX-M-15<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CTX-M-14&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">K&#46; pneumoniae</span> &#40;CTX-M-14&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of Enterobacterales and enzymes among the 35 positive rectal swabs&#46;</p>"
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      1 => array:8 [
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Positive results were considered the detection of ESBL&#47;pAmpC producers&#46; Negative results were considered lack of growth or growth of third-generation cephalosporins resistant Gram-negative but not ESBL&#47;pAmpC producers&#46;</p>"
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">UHBL results</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; of 3CGRE positive samples</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; of 3CGRE negative samples</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">At 6&#46;5<span class="elsevierStyleHsp" style=""></span>h</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results with routine culture medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">155&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2392690.png"
              ]
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">At 10<span class="elsevierStyleHsp" style=""></span>h</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results with routine culture medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                    0 => array:2 [
                      "titulo" => "AmpC disk test for detection of plasmid-mediated AmpC &#946;-lactamases in Enterobacteriaceae lacking chromosomal AmpC &#946;-lactamases"
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                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 2529993X
Original language: English

DOI:10.1016/j.eimce.2019.11.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	2	1	3
2024 October	10	6	16
2024 September	12	8	20
2024 August	14	3	17
2024 July	12	6	18
2024 June	7	6	13
2024 May	17	3	20
2024 April	20	5	25
2024 March	12	2	14
2024 February	14	3	17
2024 January	7	4	11
2023 December	16	4	20
2023 November	16	5	21
2023 October	16	5	21
2023 September	8	3	11
2023 August	6	5	11
2023 July	6	4	10
2023 June	3	11	14
2023 May	8	1	9
2023 April	9	5	14
2023 March	9	7	16
2023 February	10	4	14
2023 January	10	7	17
2022 December	12	7	19
2022 November	22	4	26
2022 October	19	11	30
2022 September	15	15	30
2022 August	42	10	52
2022 July	38	7	45
2022 June	11	7	18
2022 May	6	5	11
2022 April	15	7	22
2022 March	36	3	39
2022 February	28	5	33
2022 January	36	7	43
2021 December	34	8	42
2021 November	9	8	17
2021 October	12	8	20
2021 September	7	9	16
2021 August	7	2	9
2021 July	12	3	15
2021 June	16	9	25
2021 May	30	8	38
2021 April	18	21	39
2021 March	1	0	1

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