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            "entidad" => "Servicio de Microbiolog&#237;a y Unidad de Investigaci&#243;n&#44; Hospital Universitario Son Espases&#44; Instituto de Investigaci&#243;n Sanitaria Illes Balears &#40;IdiSBA&#41;&#44; Centro de Investigaci&#243;n Biom&#233;dica en Red de Enfermedades Infecciosas &#40;CIBERINFEC&#41;&#44; Palma de Mallorca&#44; Spain"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Programas de optimizaci&#243;n del uso de antimicrobianos en hospitales&#58; gu&#237;a de recomendaciones de expertos para actividades en poblaciones espec&#237;ficas&#44; s&#237;ndromes y otros aspectos &#40;PROA-2&#41; de la SEIMC&#44; SEFH&#44; SEMPSPGS y SEIP"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Antimicrobial stewardship in specific populations</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Guidance recommendations for antimicrobial stewardship programs in critically-ill patients admitted to Intensive Care Units &#40;ICUs&#41;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Structured antimicrobial stewardship programs &#40;AMSP&#41; should be implemented in all ICUs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">AMSP in the critical care setting should be led by an expert ICU staff member and implemented by a collaborative and multidisciplinary team including&#44; infectologists&#44; microbiologists&#44; pharmacists&#44; preventive medicine specialists and other specialists as needed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Specialists of preventive medicine will form part of AMSP&#44; for the coordination of outbreak control actions and other preventive measures to implant &#40;patient hygiene&#44; asepsis and antisepsis measures in taking samples&#44; etc&#46;&#41; for invasive procedures device monitoring&#44; for surveillance and monitoring of surgical prophylaxis&#44; and for control of environmental biosafety in controlled environment rooms in order to minimize infection transmission and prevent the appearance of outbreaks of environmental origin&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The design and implementation of AMSP in critically ill patients should consider the specificities of this patient population&#46; Infection severity&#44; organ dysfunctions and changes in pharmacokinetics should be taken into account&#46; Therapeutic drug monitoring&#44; if available&#44; is helpful for dose adjustments in ICU patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Collaborative&#44; non-compulsory interventions including audit and feedback should be prioritized&#46; De-escalation and shortening of treatments should be the main targets&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">AMSP in critically ill patients should be fueled by real-time microbiological information and clinical microbiologists support&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Updated knowledge of the local epidemiology is mandatory to design the antibiotic policy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Guidance recommendations for antimicrobial stewardship programs in haematological patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">AMSP should be developed by a multidisciplinary team including haematologists&#44; infectious diseases experts&#44; microbiologists&#44; preventive medicine specialists and pharmacists&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patterns of antimicrobial prescription and antimicrobial resistance should be monitored periodically&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The implementation of screening samples to detect colonization by multidrug-resistant organisms &#40;MDRO&#41; may be considered&#44; at least in patients at highest risk&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Antimicrobial prophylaxis&#44; empirical and streamlined therapy for febrile neutropenia should be protocolized considering local epidemiology and different patient risk profiles&#46; Adherence to recommendations should be measured&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">On-demand availability of infectious diseases experts&#44; clinical microbiologists and pharmacists should be warranted&#44; at least for the most complex cases&#44; and also specialists in preventive medicine in order to control outbreaks or isolation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Periodical&#44; regular&#44; multidisciplinary rounds are recommended&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Guidance recommendations for antimicrobial stewardship programs in solid cancer patients</span><p id="par0070" class="elsevierStylePara elsevierViewall">Specific local guidelines for the treatment of the most frequent infectious syndromes in patients with solid tumors &#40;not only febrile neutropenia&#41; based on local epidemiology&#44; must be developed by the AMSP team and oncologists&#46; Implementation of clinical pathways is more complex but also useful&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The AMSP should include availability of infectious diseases specialists for consultation&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Continuous active training on appropriate antimicrobial use must be implemented&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Interventions specifically targeting febrile neutropenia&#44; antifungal stewardship or biomarker-based algorithms may have a limited impact on patients with solid tumors and should not be prioritized&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Research is needed regarding optimal duration of antimicrobial treatments or the clinical impact of rapid diagnostic tests in this setting&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Guidance recommendations for antimicrobial stewardship programs in patients near the end of life</span><p id="par0095" class="elsevierStylePara elsevierViewall">To develop local protocols with criteria helping in the identification of patients who will most probably benefit from antibiotics &#40;i&#46;e&#46; improvement in survival or symptom relief while maintaining the quality of life&#41; and those in which avoiding futile treatments&#44; developed by palliative care experts and the AMSP team&#46; The antibiotics and routes to be used in the most frequent syndromes and rules for early stopping should be included&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A multimodal approach targeting physicians&#44; patients and care-givers&#8217; perceptions is also recommended&#46; Availability of consultation to palliative care and infectious diseases specialists is recommended&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Research is needed about the optimal approach for developing and implementing AMSP in palliative care&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Guidance recommendations for antimicrobial stewardship programs in children</span><p id="par0110" class="elsevierStylePara elsevierViewall">The AMSP team should include an expert paediatrician in infectious diseases and antimicrobial use for the activities in paediatric population&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Overall&#44; the principles of AMSP in adults are applicable to children&#59; however&#44; two aspects must be considered&#58; &#40;a&#41; local protocols for antimicrobial use in children should not be simple dose-adjusted transcriptions of protocols for adults but be specifically developed&#44; and &#40;b&#41; evidence for some interventions is more limited in children than in adults&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The fact that viral infections are more frequent as cause of acute respiratory infections in children should be outlined&#44; and availability of appropriate diagnostic methods must be considered in order to help avoiding the unnecessary use of antibiotics&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">For monitoring antimicrobial consumption&#44; days of therapy &#40;DOT&#41; per 1000 patient-days is the preferred indicator&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Guidance recommendations for antimicrobial stewardship programs in patients attended at emergency departments &#40;ED&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Multidisciplinary antimicrobial stewardship team with knowledge of the specific barriers for implementation of AMSP in the local ED must be formed&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Local empirical treatment guidelines with input from local epidemiology must be available for ED faculty&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Appropriate training for the basic aspects of infectious diseases diagnosis and treatment must be provided&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Specific appropriate clinical outcome indicators and evaluations of quality of prescriptions must be measured&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The coordination activity of preventive medicine specialists with primary care doctors or community centres or residences&#44; responsible for the continuity of antibiotic treatments&#44; will be essential&#46; This activity will make it possible to change the antibiotic when the patient has attended the ED where he has received the antibiotic of choice and has gone home&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">If individualized data on antibiotic prescriptions are not automatically available&#44; pooled data weighted by the number of patients attended at the department &#40;daily defined doses &#91;DDD&#93; per 100 patients admitted in the observation area&#44; DDD per 100 patients discharged from de ED&#41; may be considered&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Antimicrobial stewardship for specific syndromes and surgical prophylaxis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Guidance recommendations for antimicrobial stewardship programs in community-acquired pneumonia &#40;CAP&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Increased adherence to CAP guidelines must be an objective of AMSP&#46; Indicators for the measurement to adherence of the principles of treatment of CAP must be implemented&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Empirical therapy in CAP must be locally protocolized according to guidelines&#44; considering patients&#8217; severity and local epidemiology&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Adherence to early antibiotic de-escalation&#44; switch to oral therapy and short courses of therapy must be objectives of AMSP&#46; Barriers for the implementation of these two strategies may be overcome by appropriate educational interventions&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Research regarding the effectiveness of rapid diagnostic molecular tests as a stewardship tool in CAP is needed&#59; however&#44; these techniques should be considered in advanced AMSP with evaluation of results&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The use of procalcitonin is useful to improve antibiotic use in patients with CAP&#44; and may be incorporated as an aid tool together with appropriate clinical workout&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Guidance recommendations for antimicrobial stewardship programs in urinary tract infections &#40;UTI&#41;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Empirical antimicrobial therapy in UTI should be based on local guidelines&#46; These guidelines should take into account local bacterial resistance rates&#44; individual risk and severity of infections&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Antimicrobial stewardship teams should provide advice for optimizing directed therapy in UTI caused by MDRO&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Interventions to avoid the inappropriate use of antibacterials in asymptomatic bacteriuria must be implemented&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Interventions to improve adherence to short treatments according to specific type of infection and patients characteristics must be implemented&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Audits with feedback in selected patients or targeted microorganisms may be considered&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Guidance recommendations for antimicrobial stewardship program in vascular catheter-related bloodstrem infections &#40;VCA-BSI&#41;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Promote the appropriate diagnosis and management of VCA-BSI by providing adequate training and adherence to guidelines&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Specifically&#44; appropriate duration of therapy of VCA-BSI should be promoted&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Bacteraemia programs&#44; in which unsolicited advice and follow-up is provided for all patients with bacteraemia &#40;or at least for high risk patients and pathogens&#41; should be implemented&#59; measurement of adherence to quality-of-care indicators is recommended&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Guidance recommendations for antimicrobial stewardship programs in surgical antimicrobial prophylaxis &#40;SAP&#41;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Local adaptations of guidelines for SAP in all procedures performed in the hospital&#44; agreed with surgeons and anaesthesiologists&#44; should be available&#46; The local guidelines must include the antibiotics of choice and alternatives&#44; as well as the appropriate timing&#44; dosing and duration of antibiotic prophylaxis&#46; It is important to enhance other prophylactic measures and their implementation carried out by preventive medicine specialists&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Training about the principles of SAP should be provided to all staff involved&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Regular audits about adherence to local guidelines using standardized indicators must be performed&#44; and feedback provided&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Specific interventions to improve SAP must be considered according to local resources and problems detected&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Other aspects of antimicrobial stewardship programs</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Guidance recommendations for antimicrobial stewardship programs in aspects related to routes and ways of administration of antimicrobials</span><p id="par0245" class="elsevierStylePara elsevierViewall">The different routes for antimicrobial administration&#44; and the different modes of intravenous perfusions should be considered in local protocols&#59; AMSP must include activities aiming at providing the most appropriate way to administer antibiotics to the patients&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Timely switch to oral therapy when indicated must be an objective for AMSP&#44; and activities encouraging this practice should be implemented&#59; they should include actions to avoid longer treatments once the oral route is started&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Infusion pumps facilitate the correct administration of intravenous antimicrobials and must be used in circumstances in which extended or continuous perfusions are considered critical for the patient&#46; Handling of these devices must be carried out by trained personnel&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Implication of nurses in AMSP is key in order to assure an appropriate administration of antibiotics&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Guidance recommendations for antimicrobial stewardship programs in aspects related to new antimicrobials</span><p id="par0265" class="elsevierStylePara elsevierViewall">AMSP should promote the inclusion of new drugs in hospital formularies according to local needs and best evidence&#44; in order to provide patients with the best available therapy in infections caused by MDRO&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">AMSP should include local consensus guidelines including specific indications of use of new drugs according to the best available evidence and local epidemiology&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">AMSP should implement non-compulsory interventions as auditing and feedback to facilitate the adherence to the established guidelines&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">AMSP should monitor and evaluate the data concerning the outcomes of patients treated with new drugs&#44; development of resistance to them and their impact in the overall epidemiology of MDRO&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Guidance recommendations for application of social sciences and behavioural change in antimicrobial stewardship programs</span><p id="par0285" class="elsevierStylePara elsevierViewall">Antimicrobial stewardship interventions should be designed considering knowledge from behavioural and social sciences and should employ behaviour change techniques&#46; Whenever possible&#44; behaviour experts should be part of antimicrobial stewardship teams&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The prescribing behaviours that are intended to be changed should be precisely defined&#44; and barriers and promoters should be analyzed locally&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Behaviour change techniques &#40;BCTs&#41; should be selected taking into account the main determinants of the desired and&#47;or undesired behaviours&#46; The interventions must combine several BCTs&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">There are several behaviour&#39;s change theories and models that can be applied in the field of AMS&#46; One of the most frequently adopted models for AMS is the behaviour change wheel&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">It is advisable to conduct process evaluations of ongoing interventions in order to learn why they fail or succeed&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Guidance recommendations for e-tools implementation in antimicrobial stewardship programs</span><p id="par0310" class="elsevierStylePara elsevierViewall">Whenever possible and feasible&#44; e-tools should be included in AMS interventions to facilitate guidelines&#44; clinical pathways and post prescription review&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">The efficacy and safety of AMS e-tools should be validated through cluster randomized control trials or adequately controlled quasi-experimental designs&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">AMS e-tools should be available for prescribers&#46; Social media may be considered as tools to disseminate the AMSP resources&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Diagnostic stewardship</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Guidance recommendations for diagnostic stewardship</span><p id="par0325" class="elsevierStylePara elsevierViewall">Diagnostic stewardship principles should be part of any AMSP&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The adequacy of laboratory test requests and correct handling of specimens should be promoted among the activities of the AMSP&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Rapid microbiological diagnostic techniques for the adequate samples and patients&#44; and rapid identification and susceptibility testing from positive blood cultures should be implemented and associated with rapid active reporting and antimicrobial stewardship interventions&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">The use of rapid viral diagnostic testing for respiratory pathogen should be promoted in the appropriate settings&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Non-culture-based fungal markers in patients with haematological malignancies at risk of invasive fungal infections must be implemented and associated with appropriate interpretation criteria to both improve diagnosis and facilitate adequate use of antifungals&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Fast-track protocols for selected patients &#40;critical or immunocompromised patients&#41; must be designed and implemented&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Provide cascade or selective reporting instead of over-reporting all tested antimicrobials&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Provide periodical data on cumulative antimicrobial susceptibility for optimizing empirical therapy&#44; with appropriate stratification of data whenever possible&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Surveillance programs of multidrug-resistant pathogens for the detection of outbreaks and emerging new clones must be implemented&#46;</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0420" class="elsevierStylePara elsevierViewall">This document has not received any kind of funding&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0370" class="elsevierStylePara elsevierViewall">No conflicts of interest to disclose&#58; JR-B&#44; JLA&#44; ECalbo&#44; LE&#44; AFP&#44; JGR&#44; JG&#44; MVGN&#44; SG&#44; CG&#44; CM&#44; JM&#44; JRPP&#44; MTPR&#44; PRB&#44; PV&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">EC has participated as a speaker at scientific meetings sponsored by Pfizer&#44; MSD and Shionogi&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">JPH has participated in advisory boards and as a speaker at scientific meetings sponsored by Pfizer&#44; MSD&#44; Menarini&#44; Angelini&#44; and Zambon&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">NL has participated as a speaker at scientific meetings sponsored by Accelerate Diagnostics&#44; bioM&#233;rieux&#44; Menarini&#44; MSD&#44; Pfizer&#44; and Shionogi&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">XN has participated as a speaker at scientific meetings sponsored by Pfizer&#44; Gilead&#44; and MSD&#44; and in advisory boards for Gilead&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">AO has participated as a speaker at scientific meetings sponsored by Pfizer&#44; MSD&#44; and Shionogi&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">PR has participated as a speaker at scientific meetings sponsored by Pfizer&#44; MSD&#44; Novartis&#44; Menarini&#44; Gilead&#44; Becton-Dickinson&#44; and Shionogi&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">PRG has participated as a speaker at scientific meetings sponsored by Biom&#233;rieux&#44; Shionogi&#44; and MSD&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In 2012&#44; The Spanish Societies of Infectious Diseases and Clinical Microbiology &#40;SEIMC&#41;&#44; Hospital Pharmacy &#40;SEFH&#41;&#44; and Preventive Medicine&#44; Public Health and Healthcare Management &#40;SEMPSGS&#41; lead a consensus document including recommendations for the implementation of antimicrobial stewardship &#40;AMS&#41; programs &#40;AMSP&#59; PROA in Spanish&#41; in acute care hospitals in Spain&#46; While these recommendations were critical for the development of these programs in many centres&#44; there is a need for guidance in the development of AMS activities for specific patient populations&#44; syndromes or other specific aspects which were not included in the previous document or have developed significantly since then&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The objective of this expert recommendation guidance document is to review the available information about these activities in these patient populations or circumstances&#44; and to provide guidance recommendations about them&#46; With this objective the SEIMC&#44; SEFH&#44; SEMPSPGS&#44; the Spanish Society of Intensive Care Medicine &#40;SEMICYUC&#41; and the Spanish Pediatric Infectious Disease Society &#40;SEIP&#41; selected a panel of experts who chose the different aspects to include in the document&#46; Because of the lack of high-level evidence in the implementation of the activities&#44; the panel opted to perform a narrative review of the literature for the different topics for which recommendations were agreed by consensus&#46; The document was open to public consultation for the members of these societies for their comments and suggestions&#44; which were reviewed and considered by the panel&#46;</p></span>"
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